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THE . • 

MEDICAL AND SURGICAL 
REPORTER 

EDITED BY 

EDWARD T. REICHERT, M. D. 



DECEMBER TO JUNE, 1892. 



VOL. LXV/, 



PHILADELPHIA : 
THE BUTLER PUBLISHING COMPANY, 
P. 0. BOX, 843. 
1892. 



CONTRIBUTORS. 



ADAMI, J. G., M. A., M. B., Cambridgfe, England. 
ALLEN, MARY E., M. D., Philadelphia. 
ANDEKS, JAS. M , M. D., Philadelphia. 
ASHTON, W. B., M. D., Philadelphia. 
BLAIR, Louis E., M. D., Albany, N. Y. 
BALDY, J. M., M. D., Philadelphia. 
BARKER, T. RIDGWAY, M. D., Philadelphia. 
BARR, MARTIN W., M. D., Brookline, Mass. 
BLASCHKO, A., M. D., Berlin, Germany. 
BINKERD, A. D., M. D., West Monterey, Pa. 
BOKENHAM, T. J., L. R. C. P., M. R. C. S., London, 

[England. 

BREMER, L., M. D., St. Louis, Mo. 
BRISTOWE, J. SNYDER, M. D., F. R. S., London, 

[England. 

CANON, P., M. D., Berlin, Germany. 
GARY, CHAS., M. D., Buffalo, N. Y. 
CHARCOT, PROF., Paris, France. 
CLARK, E. S., M. D., San Francisco, Cal. 
COBLEIGH, E. A., M. D., New York. 
COE, HENRY C, M. D., New York. 
COPLIN, W. M. L., M. D., Philadelphia. 
CORSON, HIRAM, M. D., Plymouth Meeting, Pa. 
CRAIG, JOSEPH D., Albany, N. Y. 
CROTHERS, T. D., M. D., Hartford, Conn. 
CURRIER, JOHN M., M. D., Newport, Vermont. 
DALY, W. H,, M. D., Pittsburg, Pa. 
DELAFIBLD, FRANCIS, M. D., New York. 
DE LAPERSONNE, PROF., Lille, France. 
D'EVELYN, FRED., W. D., M. D., San Francisco^ 

[Cal! 

DIXON. ARCH, M. D., Henderson, Ky. 
DUCAMP, PROF., M. D., Montpelier, France. 
DUPLAY, PROF., Paris, France. 
EDS ALL, F. H.; M. D., Pittsburg, Pa. 
ENFIELD, A., M. D., Bedford, Pa. 
FARNSWORTH, P. J., M. D., Clinton, Ohio. 
FITCH, C. M., M. D., Chicago, 111. 
FLORAND, DR„ Paris, France. 
FROMMBL, PROF. R., Erlangen, Germany. 
FRAENKEL, A., M. D., Berlin, Germany. 
FRANK, LOUIS FRANK, M. I^., I^ilwaukee, Wis. 
FRAUNFELTER, JA-S., -M. I>.; Canton Ohio. 
GOODELL, WILLIAM, M, D., Philadelphia. 
GRIFFITH, J. CROZER, M. D., Philadelphia. 
HAGGARD, W. D., M. D., Nashville, Tenn. 
HALLUM, J. W., M. D., Carrollton, Ga. 



HAMILTON, JOHN B., M. D., Chicago, HI. 
HARRIS, ROBERT P., M. D., Philadelphia. 
HASENCAMP, 0., M. D., Toledo, Ohio. 
HEIS.ING, A. F., M. D., Menominie, Wis. 
HELFERICH, PROF., Griefswald, Germany. 
HERRICK, J. B., M. D., Chicago, 111. 
HIRSH, A. B., M. D., Philadelphia. 
HUCHARD, H., M. D., Paris, France, 
HUNTER, WM., M. D., M. R. C. P., London, England. 
HUTINOL, DR., Paris, France. 
JACKSON, EDWARD, M. D., Philadelphia. 
JENKINS, R. J., M. D., Shelbyville, Ind. 
JEWETT, CHAS. H., Brooklyn, N. Y. 
KANTHACK, A. A., F. R. C. S., London, England. 
KBYSER, P. D., M. D., Philadelphia. 
KINNICUTT, FRANCES P., M. D., New York. 
KLEIN, B., M. D., London, England. 
KIRKPATRICK, A. B., D., Philadelphia. . 
KITASATO, S., M. D., Berlin, Germany. 
KOENIG, AUGUST, M. D., Pittsburg, Pa. 
KONIG, DR. FRANZ, Gottingen, Germany. 
LEWIS, G. C, M. D., Fairbury, 111. 

LINDNER, PROF. H., BerUn, Germany. 4. 
LINVILLE, MONT., M. D., New Castle, Pa. 
LOOMIS, ALFRED L., M. D., New York. 
LYDSTON, G. FRANK, M. D., Chicago, 111. 
MAC DONALD, ARTHUR, Washington, D. C. 
MANLEY, T. H., M. D., New York. 
MANN, M. D., M. D., Buffalo, N. Y. 
MANSFIELD, ARTHUR D., M. D., Baltimore, Md. 
MARTIN AND CRAWFORD, Kahoka, Mo. 
MARTIN, SYDNEY, M. D., London, England. 
MASSEY, G. BETTON, M. D., Philadelphia 
MAYO, FLORENCE, M. D., Philadelphia. 
McBURNEY, CHARLES, M. D., New York. 
McCANN, JAS., M. D., Pittsburg, Pa. 
McGIRK, JOHN D., M. D., Philipsburg, Pa. 
MILLS. CHAS. K., M. D., Philadelphia. 
MONTGOMERY, B. E., M. D., Philadelphia. 
kooiM't!. -C, M. D., Philadelphia. 
MYNTBR, HERMANN D., Buffalo, N. Y. 
NOBLE, CHAS. P., M. D,, Philadelphia. 
PACKARD, JOHN H., M. D., Philadelphia. 
PALMER, C. D., M. D., Cincinnati, Ohio. 
PARK, ROSWELL, M, D., Buffalo, N. Y. 
PATTON, JOSEPH M., M. D., Chicago, 111. 
PERDUE, H., M. D., Barnsville, Ga. 



Contributors. 



iii 



PETEl iESSOR, Pari?, France. 

PFItri ER, R., M. D., Berlin, Germany. 
POTSDAMER, JOS. B., A. M., M. D., Philadelphia. 
PRENGRUBER, PROP., Paris, France. 
PRINCE, J. A., M. D., Springfield, 111. 
REYNOLDS, F. R., M. D., Eau Claire, Wis. 
ROBERTS, JOHN B., M. D., Philadelphia. 
ROSS, ALICE McLEAN, M. D., Swatow, China. 
RUFFER, M. ARMAND, M. D., London, England. 
SANDERSON, E. BURDON,M. D., London, England. 
SCHNEIDEMAN, T. B., M. D., Philadelphia. 
SCHWEINITZ, GEO. E., M. D., Philadelphia. 
SELIGMAN, L., M. D., Hamburg, Germany. 
SHAFFER, J. M., M. D., Keokuk, la. 
SHIMWELL, BENJ. T., M. D., Philadelphia. 
SIMON, JULES, M. D., Paris, France. 
SMITH, A. A., M. D., Awkinsville, Ga. 
SMITH, HENRY R., M. D., Detroit, Texas. 
SOLIS-COHEN, SOLOMON, M. D., Philadelphia. 
STEELE, G. M., M. D., Oshkosh, Wis. 
STELWAGON, HENRY W., M. D., Philadelphia. 
STEWART, JOHN S., M. D., Philadelphia. 
STIMPSON, A. 0., M. D., Thompson, Pa. 



STOCKTON, CHAS. S., M. D., Buffalo, N. Y. 
TAIT, DUDLEY, M. D., San Francisco, Cal. 
TAYLOR, J. MADISON, M. D., Philadelphia. 
THOMAS, G. D., M. D., Chicora, Pa. 
THOMPSON, J. B., M. D., Atlantic City, N. J. 
TREMINE, WM. A., M. D., Providence, R. I. 
TUCKER, J. P., M. D., Overton. Texas. 
TURNBULL, LAURENCE, M. D., P. H. G., Phila- 

[delphia. 

TURNER, JOHN B., M. D., Philadelphia. 
WALBRIDGE, L. P., M. D., Decatur, 111, 
WARD, M. B., Topeka, Kan. 
WERDER, X.O., M. D., Pittsburgh, Pa. 
WERNER, MARIE B., M. D., Philadelphia. 
WIGHT, J. S., M. D., Brooklin, N. Y. 
WILLARD, DeFORREST, M. D., Philadelphia. 
WILLIAMS, CHAS. B., M. D., Philadelphia. 
WILLIAMS, ROGER, M. D., Pittsburg, Pa. 
WILSON, H. AUGUSTUS, M. D., Philadelphia. 
WILSON, 0. W., M. D., Lawrence, Kansas. 
WOODHEAD, G. SIMS, M. D., London, England. 
WRIGHT, ALMROTH, M. D., London, England. 
ZENNER, PHILIP, M. D., Cincinnati, Ohio. 



INDEX 



Abdominal section, 486 • after-treatment, 692. 

Abortion, ether injection after, 316; induction of, 
effective method for, 315 ; nitric acid in criminal, 
674; rapid induction with the curette, 913; threat- 
ened, opium enemata in, 112 : treatment, 514 ; hab- 
itual, asafoetida for, 996; puerperal tetanus after, 
994; tubal, 951. 

Abrin and ricin in eye and other affections, 425 ; 

Abscess, cerebral, 634 ; of the anterior vaginal wall, 88 ; 
of kidneys, 882; mammary, prevention of, 555 ; 
management of, 355; of the breast, 201; retro- 
pharyngeal, in children, treatment, 911; psoas, 
treatment by injections of iodoform, 992 ; tuberculous 
retro-pharyngeal, treatment, 990. 

Acacia, gum of South Africa, 798. 

A. C. E., mixture, 520. 

Acetanilide and salicylic acid, 399. 

Acetanilide for the preservation of hypodermic solu- 
tions, 278 ; 

Acetone, reagent for, 118. 

Acetonsemia, cerebral, 270. 

Acetonuria in the insane, 238. 

Acid, borax-boric, 238; filicic, action and uses of, 107; 
salicylic, as a diuretic, 40 ; irrigation of, in the treat- 
ment of diphtheria, 78. 

Acids, fatty, in defatted cotton, 319. 

" A clear statement," 840. 

Actinic light, effect of fog on, 280. 

Adami, J. G. — Phagocytosis, 537. 

Advertisements, interleaved, 439. 

Agnew, D. Hays — Obituary, 580 ; minute, 599. 

Air in parturition, 273. 

Air passages, foreign bodies in, 591 ; methyl violet in 
affections of, 425 ; the treatment of catarrhal affec- 
tions of, 21. 

Albumin in urine, test for, 675, 839, 878. 

Albuminuria and nephritis, treatment of, in pregnancy, 
112. 

Albuminuria and renal circulation, relations between, 
150, 

Albuminuria, relation of to surgical operations, 232 ; 

in syphilis, 587. 
Alcohol and death rates, 237. 
Alcohol and nerve-centres, 371. 
Alcohol and the nervous system, 116. 
Alcohol, as a food, 517. 
Alcoholism and tuberculosis, 918. 

Alcoholic beverages, administration to children, 597. 
Alcohol disease from a physiological aspect, 450. 
Alcoholic injections in the treatment of reducible her- 
nia, 151. 
Alcoholic neuritis, 351. 
Alkaloidal assay of narcotic plants, 158. 
Alkaloids and alcohol, 999. 

Allen, Mary E., M. D. — Premature baldness, 869. 
Alopecia areata and trichorrhexis, 403. 
Amenorrhoea in school-girls, 555. 
American Electro-therapeutic Association, 760. 
American Pharmaceutical Association, 119. 
American Neurological Association, 999. 



-Americans in the Riviera, 80. 
American Surgical Association, 840. 
Amaurosis and albuminuria of pregnancy, 592. 
Amputation of the leg under cocaine anaesthesia, 152. 
Amylene, hydrate of, in epilepsy, 268. 
Amylhydrate as a hypnotic, 903. 

Angesthesia, local, produced by injection of water, 66; 
local and general, 104; in pregnancy and diseases of 
women, 994. 

Angesthetic new, pental, 193, 939, 948; warm ether as, 
271, 308. 

Anders, Jas. M., M. D., Combined cardiac lesions, 164; 

epidemic influenza, 445. 
Angina pectoris, 589; treatment of, by cocaine, 104, 

144. 

Anthrax, ipecacuanha in, 224. 

Antibiotic substances, 492. 

Antiperiodic, methylene-blue as, 388. 

Antipyretics, hypnotic action of, 102; and pyrexia, 
271; in childhood, 77. 

Antipyrine in hepatic colics, 389 ; reaction, new, 741 ; 
to dry up the milk secretion, 593, 707; gangrene fol- 
lowing injections of, 709 ; in whooping-cough, 768 ; 
in chorea, 795, 65 ; in affections of the pharynx 
and larynx, 31 ; in hemeralopia, 691. 

Antisepsis, 315 ; and puerperal mortality in Paris hos- 
pitals, 240 ; for the hands, 753. 

Antiseptics, surgical, iodine water and aristol as, 73, 
438 ; for the Grippe, 189. 

Anus, fissures of, in children, 277. 

Are colds infectious ? 199. 

Asepsis in Von Bergman's clinic, methods of carrying 
out, 230. 

Aortic insuflficiency, two types, 750. 
Aortic narrowing a new sign, 387. 
Aphthae or thrush of vulvae, 756. 

Appendicitis, medical treatment of, 84; recurring, 980. 

Aristol in rhinitis, 570. 

Army Medical Board, 80, 400. 

Arsenical cod-liver oil, 559. 

Arsenic for trichinosis, 120. 

Arsenic in common life, 758. 955. 

Arteries, ligation of, 433. 

Arterio-sclerosis, causes of, 711. 

Arthrotomy in old luxations, 70. 

Arthropathies in tabes dorsalis, 721. 

Artificial neurasthenia, 67. 

Ashton, W. E. — Intestinal anastomosis, 565. 

Asphyxia, nitro- glycerine in, 1018. 

Association of American Institutions for Idiotic and 

Feeble-minded Children, 800. 
Asthma, cocaine in, 40. 
Athetosis, general, 947. 

Atropia, subcutaneous injection of, as a haemostatic, 29. 
Automatism, epileptic, 100. 

Azoospermia, gonorrhoea, prophylactic treatment, 633. 

Bacilli, actions of phagocytes on, 491; tubercle, in the 

aqueous humor of cattle, 79. 
Bacillian infection, 997. 



Index, 



V 



Bacillus of chorea, 191, 350; of enteric fever, 33; of 
measles, 876 : of influenza, 244; of tubercle, attenu- 
ation of, 924.' 

Bacteria in drinking water, 358 ; intrauterine trans- 
mission of, 793. 

Bacteriological researches upon saliva of children 
suflFering from measles, 156. 

Bacteriology of yellow fever, 313 ; of endometritis, 755. 

Bacterium coli communis and peritonitis from in- 
testinal perforation, 670. 

Bacteria, reaction of aqueous extract from, 719. 

Baldness, causes of premature, 677, 869 ; congenital, 
837. 

Baldy, J. M., M. D. — Supra-vaginal hysterectomy, 53 ; 
chronic endometritis, 406. 

Bandages, warm, hypnotic effect of, 858. 

Barker, T. Ridgway, M. D. — Mooted points concern- 
ing the vomiting of pregnancy, 133; chloroform in 
parturition, 811. 

Barr, Martin — Acute parenchymatous nephritis, 502. 

Basedow's disease, 422. 

Bathing, hot, in Japan, 838. 

Baths, cold, in broncho-pneumonias, 960. 

Bed, deadly cold, 759. 

Beidert's method, shortening of, for finding tubercular 
bacilli in sputum, 277. 

Benzine as a preventive of trichinosis, 278 ; in pedi- 
culosis, 268. 

Benzonaphthol, 435 ; in uremia, 426. 

Benzosol as a substitute for creasote, 988. 

Bile, secretion in biliary fistula, 429. 

Binkerd, A. D. — Fracture of skull and trephining, 540; 
scalds and burns, 337 ; Dneumonitis, 730. 

Bismuth, vehicle for, 147; bromide of, 376; salicylate, 
760. 

Bladder and prostate, operations on the, 34; tumors, 

diagnosis of, 588. 
Blair, Louis E., M. D. — Pathological conditions of 

nose and throat as causal factors in asthma, 166. 
Blaschko, A., M. D. — Alopecia areata and trichorrhexis, 

403. 

Blindness, preventable, 159; temporary, during lacta- 
tion, 433. 

Blood-clot, importance of, in treating dead spaces, 
45. 

Blood in health and disease, specific gravity of, 108. 

Blood in disease, specific gravity of, 228. 

Blood of influenza patients, micro-organism of, 246. 

Blood-poisoning, 262. 

Blood and urine in the insane, 406. 

Bogus American Diploma, 159. 

Boils and their treatment, 858. 

Bokenham, T. J. — Phagocytosis, 539. 

Bone in the throat, 572, 785. 

Book Reviews : 

Abbott, A. C— Bacteriology, 347. 
Aulde, John — Pocket Pharmacy, 905. 
Brockway, Fred. J. — Essentials of Physics, 306. 
Burdett, Henry C. — Hospitals and Asylums of the 
World, 905, 

Buret, F. — Syphilis in Prehistoric Times, 347. 
Charcot, Bouchard and Brissaud — Traite de Medi- 
cine, 581. 

Chaveau,A. — Comparative Anatomy of Domesticated 

Animals, 102. 
Councilman and Laflem— Amoebic Dysentery, 424. 
Davis, N. S., Jr. — Consumption, 387. 
Forcheimer, F. — Diseases of the Mouth' in Children, 

387. 

Foster, M. — Physiology, 62. 
Gribson, Gr. A. — Physical Diagnosis, 463. 
Hamilton, John B. — Tumors, 665. 
Heron, G. A. — Communicalaility of Consumption, 
102. 

Huidekoper, Rush Shippen — Age of Domestic Ani- 
mals. 143. 

Hurd, E. P.— Sleep, Insomnia and Hypnotics, 665. 
Johnstone, Alex. — Botany, 463. 



Lovett, Robert W. — Disease of the Hip-Joint, 510. 

MacDonald, Grerille — Diseases of the Nose and Ac- 
cessory Cavities, 1017. 

Milliard, Henry B. — Bright's Disease of the Kidneys, 
1017. 

Nyman, Hal C. — Disease of the Bladder and Prostate, 
347. 

Nissen, Hartman — A. B. C. of Swedish Educational 

Gymnastics, 144. 
Osier, William — Principles and Practice of Medicine, 

631. 

Paquin, Paul — Microscopical Diagnosis of Tuberculo- 
sis, 189 ; Supreme Passions of Man, 62. 

Park, Roswell — Surgical Pathology, 742. 

Poole, W. H. and Mrs. — Cookery for the Diabetic, 
223. 

Pozzi, S. — Gynascology, 547. 

Sexton, Samuel — Cure of Deafness and Discharge from 
the Ear, 265. 

Shaw, John C. — Essentials of Nervous Diseases and 
Insanity, 28. 

Shield, Marmaduke — Surgical Anatomy, 306. 

Stewart, D. D. — Medical Electricity, 265. 

Stillman, Chas. C. — Chronic Articular Osteitis, 509. 

Sutton J. Bland — Surgical Diseases of the Ovaries and 
Fallopian Tubes, 941. 

Thomas, T. Galliard — Diseases of Women, 305. 

Thompson J. Arthur, Outlines of Zoology, 986. 

Transactions of the American Association of Obstetri- 
cians and Gynaecologists, 785; of the American 
Orthopaedic Association, 942 ; of the New York 
Medical Association, 942. 

Transactions of the American Otological Society, 
785. 

Transactions of the Medical and Surgical Faculty of 

the State of Maryland, 829. 
Tuckey, Lloyd — Psycho-Therapeutics, 868. 
Treves, Frederick — Operative Surgery, 423. 
Waller, Augustus — Physiology, 189. 
Warner's Therapeutic Reference Book, 942. 
Weeks-Shaw, Clara S.— Nursing, 868. 
Whitla, William. — Dictionary of Treatment, 985. 
Williams, P. W. — International Medical Annual and 

Practitioner's Index, 829. 
Wilson, J. C— Medical Pocket Formulary, 223. 
Wood, Casey A. — Eye Disease, 223. 
Year-Book of Treatment, 665. 

Borate of sodium in epilepsy, 819. 
Borax-boric acid, 238. 
Boron, pure^ 879. 

Brain and its membranes, contribution to the patholog- 
ical anatomy of the retina and optic nerve in diseases 
of, 110. 

Brain, bullet in for 29 years, 713. 
Brain, disease following nasal operation, 590. 
Brain, hydatid cysts of, 1. 
Brain surgery, present status, 5, 752. 
Bran, raising children on, 117. 
Bread, Russian, analysis, 519. 
Breast, abscesses of, 201 ; hypertrophy of, 995. 
Breast milk, morphology of, and nutrition of the child, 
117. 

Bremer, L. — Modern neurology, 1005. 
Bright's disease, strontium in, 425. 
Bristowe, J. Syer — Phagocytosis, 525. 
Bromamide, a new remedy, 790. 

Bromides and increased susceptibility to infection, 
633. 

Bromides, actions of, 746. 

Bromide of potassium, accumulation in different tissues, 

746. 
Bromol, 158. 
Bronchitis mixtures, 543. 

Broncho-pneumonia, treatment of in children, 308 ; 

cold baths in, 960. 
Brown-Sequard and isopathy, 600. 
Brushes, sterilization of, 109. 
Buboes, treatment of, 30. 



vi 



Index. 



Bumping, remedy for, 279, 

Burns and scalds, 337 glycerin for, 310, 180 ; treated 

by europhen, 830. 
Butter, vegetable, 116. 

Caecitas syllabaris, 311. 

Csesarean section, 453, 714, 233, 154. 

Cactus grandiflora, actions of, 907. 

Camphor, hypodermic injection of, 192. 

Camphor and thymol, hydroscopic character, 478. 

Canada, physicians in, 480. 

Cancer, peripheral neuritis in, 392 ; of the uterus, early 
diagnosis of, 197 ; primary, of the clitoris, 198 ; uter- 
ine, cause of recurrence, 875; of testicle, 991. 

Canon, P., M. D. — Micro-organism in the blood of in- 
fluenza patients, 246. 

Cantharidinates, action of, 667. 

Carbolic acid hypodermatically in tetanus, 466. 

Carbuncles, excision of, 513, 239. 

Carcinoma, of breast, 884 ; vaginal hysterectomy for, 

235; new treatment of, 310; treatment, 986. 
Cardiac grippe, 561. 
Cardiac Lesions, combined, 164. 
Cardiac tonics, 705. 
Cardiopathies, causes, 711. 
Caries of lumbar vertebrae, 608. 
Caruncle, urethral, 155. 
Cary, Chas. — Hemiplegia, 523. 
Castor oil, testing, 165. 
Cataract, simple extraction of, 88. 
Catarrh, relation to laryngeal phthisis, 990. 
Catgut infection in the dry treatment of wounds, 651. 
Cathartics, abuse of, in gyn£ecological treatment, 355. 
Catheterization of the female bladder, 714. 
Catramine, a new terbinthinate, 907. 
Cauda equina, compression of, 35. 
Caustic, lunar, preservation of, 3. 

Cauterization of the cervix and uterus, danger of, 114. 
Cautery, actual, use in gynaecology, 474. 
Cellulitis, 921. 
Cephalic tetanus, 226. 
Cerebral acetonaemia, 270. 
Cerebral abscess, 634. 
Cerebral atrophies in childhood, 595. 
Cerebral localization, 910. 
Cerebral surgery, present aspect of, 4, 672, 
Cerebral syphilis, 350. 
Cervix, chancres of, diagnosis of, 114. 
Cervix, racemose sarcoma of, 235. 
Chancre, hard on lip and soft on genitals, 539. 
Chancroid, concealed with sloughing, 807. 
Characteristics of the present pandemic of influenza, 
200. 

Charcot, Prof. — Intermittent claudication, 361 ; Arthro- 
pathies, 721. 
Chaulmoogra oil in leprosy, 906. 
Cheese, digestibility, 796. 
Chemotaxis, 492, 493. 
Chests, medical, on railroads, 471. 
Chicken-pox, complications, 557. 
Childbed, prurigo in, 273. 
Children, young, errors in feeding, 115. 
Chirography and merit, 560. 

Chloral, action of Borax on, 760 ; as a hypnotic, 904. 

Chloralamide, as a hypnotic, 383 ; eflFect of heat on, 559. 

Chlorine water and quinine in typhoid fever, 465. 

Chloroform, drop by drop method of administering, 458. 
rapid anaesthesia with, 467; in obstetrics, 592; im- 
pure, toxic effects of impure, 667. 

Chlorosis, febrile, remarkable case, 908 ; scarification of 
OS uteri in, 675. 

Choleodochotomy, case, 590. 

Cholera, aetiology and toxicology, 459. 

Chorea, 262; antipyrine in, 65, 795 ; and epilepsy, rela- 
tion between, 629 ; bacillus of, 191, 250 ; exalgin in, 
594, 676. 

Circumcision, endocarditis following, 505. 
City dust, 276. 

Class Banquet, Jefferson Medical College, 119. 



Claudication, intermittent, 361 ; as a diagnostic sign in 

doubtful cases of diabetes, 909. 
Clark, E.S., M. D. — Disease of the mastoid process, 770. 
Clavicle, simple fractures of, suture in, 313, 
Climate-therapy, cardinal truth of, 986. 
Climatic treatment of phthisis at Colorado Springs, 15. 
Clitoris, cancer of, 36 ; primary cancer of, 198. 
Cobleigh, E. A., M. D. — Molluscum fibrosum, 847. 
Coca, as a prophylactic against influenza, 144; East 

Indian, 438. 

Cocaine in pertussis, 236; in treatment of angina pec- 
toris, 144; anaesthesia in amputation of the leg, 152 ; 
in the treatment of angina pectoris, 104; laparotomy 
under, 715; ansesthesia in enucleation of eye, 652; 
poisoning, prevention of, 704, 1010 ; death from, 668 ; 
in peritonitis, 348. 

Codeine : Its physiological action and therapeutic 
employment, 1005. 

Cod-liver oil, arsenical, 559. 

Coe, Henry C., M. D. — Examination of young girls, 761. 
Coffee as an antiseptic, 1018. 
Coffee-tea, 476. 

Conjunctivitis, granular, new treatment of, 104. 

Colchicine for the eye, 425. 

Cold in treatment of yellow fever, 348. 

Colic, treatment, 757 ; hepatic, antipyrin in, 789 ; sodium 

salicylate in, .40. 
Colitis, 121. 

Colotomy, indications for, 792. 

Colles fracture, 283. 

Color reaction for salol, 199. 

Colorado Springs in the climatic treatment of phthisis, 
15. 

Colotomy, 922. 

Coma, diabetic, case of, 297. 

Composition of tuberculin, 199. 

Compressed medicine to be used in the army and navy, 
160. 

Conjunctivitis, granular, treatment, 949. 

Convulsions, tetanoid, operation for, 72 ; infantile fre- 
quency of, 77 ; tetanoid, in an infant, 607; in chil- 
dren, treatment of, 275; treated by compression of 
the carotid, 510. 

Copaiba balsam as a diuretic, 550. 

Coplin, W. M. L., M. D.— Strictured male urethra, 734. 

Corn cures, 633. 

Cornea, artificial, ^72. 

Cornutin as a haemostatic in hsemorrhages from the 

bladder and female genitals, 103. 
Corset and the stomach, 638. 

Corson, Hiram, M. D. — Pneumonia and its treatment, 
824. 

Coryza, acute, treatment, 549. 
Costotomy, 672. 

Cotton, defatted, presence of fatty acids in, 319. 
Craig, Joseph D., M. D. — Foreign bodies in the stom- 
ach, 366. 
Craniectomy, 636. 

Craniotomy in microcephali in undeveloped children, 
917. 

Cremation, burial and exhumation, 440. 
Cresol solutions, 31. 
Cripples, better treatment for, 360. 
Crothers, T. D., M. D. — New studies of the opium dis- 
ease, 372. 

Croup, treatment, 412 ; laryngeal etherization in, 225, 

317; intubation in, 117. 
Croupous pneumonia in children, treatment, 716. 
Currier, John M., M, D. — Diaphragmatic hernia, 371 ; 

bone in throat, 786. 
Cystitis, acute gonorrhoeal, 590, 947 ; treatment with 

mercuric eoloride, 789, 
Cystoma, ovarian, 339, 515. 
Cystotomy, supra-pubic, 321, 1011. 

Daly, W. H., M. D.— Leprosy, 648. 
Death-rates and alcohol, 237. 
Defascation, oral, 940. 

Degeneration of the solar plexus in the insane, 269. 



Index. 



vii 



Delafield, Frances, M. D. — Chronic colitis, 121. 
De Lapersonne, Prof. — Aetiology of iritis, 885. 
Dental instruments, disinfection of, 596. 
Dermatol, 389. 
Dermatology, modern, 928. 

Desquamation in Scarlatina, to hasten, 189, 310. 
Detection of fats mixed with vaseline, 279. 
D'Evelyn, Fred. W. B., M. D.— Post-diphtheritic par- 
alysis, 853. 

Diabetes, new clinical form, 351 ; syzgium in, 870 ; 

intermittent claudication as a diagnostic factor, 909 ; 

jambul in, 745 ; zona in, 468. 
Diabetic coma, case of, 297. 
Diabetics, treatment of pneumonia in, 64. 
Diagnosis of chancres of the cervix, 114. 
Diaphragmatic hernia, 371. 

Diarrhoea, 268 ; lactic acid treatment, 427 ; treatment 
of in children, 334, 1004. 

Diarrhoeal collapse, subcutaneous injection of salt solu- 
tion in, 986. 

Dietetic value uf peptones, 157. 

Diet in fever, 558. 

Digestion, is ether an assistant? 318. 

Diphtheria and scarlatina, hypodermic injection of 
corrosive sublimate in, 63 ; treatment of, by irriga- 
tion of salicylic acid, 78 ; hydrotherapy in the treat- 
ment of, 103 ; in Milan, 160 ; paraffine in, 236 ; 
treatment of, 276 ; a new treatment, 397 ; local treat- 
ment of the throat, 436; and scarlet fever, non-iden- 
tity, 516; tannin in, 480 ; germ theory from a clini- 
cal aspect, 549 ; steam as an agent in the spread, 
596 ; mortality, 628 ; treated with irrigations of sali- 
cylic acid, 637; aetiology, 717 ; papoid in, 756 ; treat- 
ment, 796, 455, 475, 973; action of ice water and ice, 
876; submembranous treatment, 476. 

Diphtherial infection of tracheotomy wounds, 397. 

Diphtheritic and diphtheroid conjunctivitis, treatment 
of, 38. 

Diplopia, double uniocular, 351. 

Disease of hip during childhood, 286, 326 ; of middle 
ear, salol camphorated, in, 309 ; syphilitic, of the 
lungs, 32 ; influence of weather on, 39 ; malignant, 
oedema as a symptom occurring in, 81; kidney with 
cardiac complications, 92; septic, of the umbilicus,196. 

Disinfectant, cheap, 638; intestinal, 633. 

Disinfection of the hands, 435 ; of rooms, 437. 

Dislocations, recurrent, injection of chloride of zinc in, 
1013. 

Disorders caused by tricocephalus dispar, 107. 
Distinguishing margarine from butter when the two 

are mingled, 157. 
Diuretic, salicylic acid as, 40. 
Diuretin, 466. 

Dixon, Arch, M. D. — Ovarian cystoma, 339. 

" Doctor would not come," 439. 

Dresses, trailing, 955. 

Drugs, recent, in medical practice, 743. 

Drunkenness, cures for, 64. 

Duboisin as a sedative and hypnotic, 559; in mental 
disease, 944. 

Ducamp, Prof., M. D; —Hydatid cysts of the brain, 1. 

Duplay, Prof. — Abscesses of the breast, 201. 

Dust, city, 276. 

Dust and dustings, 518. 

Dysentery, acute and chronic, treatment, 426. 
Dysmenorrhoea, treatment of, 356. 
Dyspepsia, sauerkraut in, 632. 

Earache, 277, 790. 

Ear, middle, camphorated salol in diseases of, 309. 
Ears, outstanding, 948. 

Echinoeoccus of liver operated on by costotomy, 672. 
Eclampsia of pregnancy, Csesarean section for, 233. 
Edsall, F. H., M. D.— Reflex headache, 727. 
Effusions, origin of, 68. 

Ehrlich's reaction in tubercular children treated with 
• Koch's lymph, 862. 

Electrical shock, histological alterations produced in 
the nerve-centres by, 947. 



Electricity in metrorrhagia, 235. 
Electricity in uterine fibroids, 274. 
Electro-gynaecology, 323. 
Electrotherapy, 263. 
Empyema, remarkable case of, 312. 
Eneuresis, nocturnal cured by excision of Luschka's 
tonsil, 875. 

Enuresis, nocturnal, in mouth-breathers, 117 ; manual 

treatment, 827. 
Enucleation for goitre, 62 cases of, 231. 
Enfield, A., M. D.— Alcohol disease, 450. 
Endocarditis following circumcision, 505. 
Endometritis, treatment of, 434, 739 ; chronic, 406 ; 

and acute infectious diseases, 515 ; bacteriology, 755; 

puerperal, histological study of, 315; subacute, in 

the later months of gestation, 994. 
Entozoa, prevention of spread, 797. 
Epidemic influenza, re-appearance of, 270. 
Epididymitis, instillations of nitrate of silver, 

552. 

Epileptic colonies, 957. 
Epileptics, visual field in, 935. 

Epilepsy, and chorea, relation between, 629 ; unusual 
manifestations of, 221; hydrate of amylene, 268; 
Jacksonian, electrolysis of cortex in, 633 ; trephining 
for, 635 ; treated by bromides and nerve sedatives, 
587 ; relation of cerebral ansemia and hyperaemia to, 
589 ; treated by trephining, 673 ; traumatic, 881 ; 
following re-vaccination, 709; influence of preg- 
nancy on, 715; borate of sodium in, 819. 

Epileptic automatism, 109. 

Episcleritis, 449. 

Epistaxis, an easy and effectual method of stopping, 
553. 

Epithelioma, 882; sulphate of magnesia in, 467. 
Ergot and ergotine, actions of, 744, 830. 
Ergotin subcutaneous use of, 1 94. 
Errors in feeding of young children, 115. 
Erysipelas, recurrent, 704. 
Erysipelas and tuberculosis, 748. 

Ether, warm, as an anaesthetic, 271, 308 ; subcutaneous 
injections of, in puerperal eclampsia, 197 ; local 
application of, in strangulated hernia, 232 ; does it 
assist digestion, 318; injection after abortion, 316; 
as a stimulant, 744 ; reaction on the urine, 919. 

Etherization in laryngeal croup, 225, 317. 

Etiology of hypefemesis gravidarum, 316. 

Eucalypto-resorcin, 399. 

Euphorin in gynaecological practice, 835. 

Exalginin chorea, 594, 676. 

Examination of the eyes of the insane, 67. 

Exercise in childhood and youth, 842. 

Expiration of carbuncle, 239 ; of the liver, results of, 
313 ; of varicosities for ulcers of leg, 313. 

Eye diseases, subconjunctival injections of corrosive 
sublimate, 467. 

Eyes of the insane, examination of, 67. 

Facial hemiatrophy, 191, 311. 
Facial paralysis, 910. 

Fallopian tube, anatomy and physiology, 875; fibroma 
of, 716. 

Faradization and galvanization in treatment of uterine 
fibroids, 240. 

Farnsworth, P, J. — Opium, belladonna and chloral 

poisoning, 971. 
Fat, effect of deep inspiration on the assimilation of, 

718. 

Feeble-minded, occupation, 1014. 
Feeding, errors in, of young children, 115. 
Fehling's solution, permanent, 838. 
Female, gonorrhoea in, 35. 

Femur, fracture of, results of treatment of, 314. 
Fetid feet, 797. 

Fever, catarrhal, treatment, 419; diet in, 558; enteric, 
bacillus of, 33 ; enteric, yeast in, 66 ; typhoid, treated 
by yeast, 147 ; typhoid, treatment of in children, 41 ; 
typhoid, condition of heart in, 70; typhoid, experi- 
mental, 228; typhoid, peroxide of hydrogen in, 224; 



viii 



Index, 



puerperal, prophylaxis of, 156 ; thermic, complicated 
by croupous pneumonia, 48 ; yellow, bacteriology of, 
313 ; of growth, general considerations, 990. 

Fibroids, uterine, electricity in, 274, 995. 

Fibroma, diffuse, of both breasts, 873. 

Fibromyoma, aetiology of, 956. 

Fibrosarcoma of nasal fossae, 675. 

Fibro-sarcomatosis, 847. 

Filiariosis, surgical, 471. 

Fingers, cut off, union of, 272. 

Fire-proofing formulae, 799. 

Fissures in the anus, 950 ; in children, 277. 

Fistula, gastric, 353. 

Fitch, C. M„ M. D. — Water as a therapeutic agent, 890. 
Florand, Dr. — Treatment of diarrhoea in children, 334. 
Florence redivius, 548. 
Fluid with meals, 318. 

Fog, effect of, on actinic light, 280 ; London, surgical 

aspects of, 711. 
Forceps, obstetric, misapplication of, 434. 

Formula: 

Abortion, habitual, 825. 

Absorbent powder. 577. 

Alcoholism, strychnine in, 220. 

Alopecia, following acute diseases, lotion for, 57. 

Alterative, 519, 900. 

Aluminum in diphtheria, 343. 

Ammonia muriate in grippe, 900. Anaemia, 662. 

Anaesthetic, local, 302, 382, 544. 

Angina, acute, 826. 

Anodyne liniment, 900. 

Anticebum pill, 577.* 

Antisepsis, intestinal, 139. 

Antiseptic adhesive ointment, 220. 

Antiseptic salve, 738. 

Arthritis, rheumatoid, 220. 

Asthma, 24, 186, 343, 420, 662, 982. 

Atony, gastro-intestinal, 24. 

Baldnesss, 578, 938. 

Beverage, refreshing, 1014. 

Bladder, irritable, 671. 

Blenorrhagia, 58. 

Blister, horse, 699. 

Brandreth's pills, 982. 

Brandy with egg, 219. 

Bronchitis, acute, 505. 

Bronchitis, chronic, 700 j mixtures, 543. 

Burns, 982. 

Cancer of uterus, disinfectant injection, 703. 

Cardiac dilatation, 420, 700. 

Cardiac tonic, 577. 

Catarrh, nasal, 458. 

Catarrh snuff, 825. 

Chancroids, 554. 

Chilblains, 506, 662, 981. 

Chloralamide, 700. 

Chloroform, compound elixir, 578. 

Chlorosis, 662, 1014. 

Cholelithiasis, 96. 

Cod-liver oil emulsion, 577. 

Cocaine, elixir, 825. 

Coca, wine of, 900, 938. 

Cod-liver oil, palatable, 700. 

Collyrium, 500. 

Comedones, 826. 

Constipation in infants, 96. 

Constipation, thiol in, 505. 

Consumption, 544. 

Coryza, 578; abortive treatment, 420; acute, 549; 

with anosmia, 863. 
Creolin-iodoform ointment, 505. 
Cough, nervous, 382. 
Creasote, compound wine of, 57. 
Croup, 344, 413. 
Cystitis, 938 ; chronic, 864. 
Dandruff, 577. 
Dermatol, 506. 

Diabetes insipidus, 828; care of teeth in, 981. 



Diarrhoea, chronic with intestinal fermentation, 382 ; 
chronic, in children, 900; in children, 544; infan- 
tile. 782 ; mixture, 900 ; resorcin in, 139 ; 937; 1014. 

Diphtheria, 826; and croup, 344; hydrochloric acid 
in, 662; laryngeal, 343; papoid in, 302; perman- 
ganate of potassium in, 825 ; topical application in, 
96, 140, 1014 

Depilatory, 661. 

Disinfectant, intra-uterine, 506. 

Diuretic remedy, 782. 

Douches, nasal, 24. 

Dropsy cardiac origin, 661. 

Dysentery, 343 ; acute and chronic, 426. 

Dysmenorrhoea, 937. 

Dyspepsia, acid, 738 : fermentive, 500 ; pyloric pain, 

937 

Dyspnoea in heart disease, 1013. 
Earache, 505. 
Eclampsia, 577. 

Eczema, 382 ; acute, 262 ; infantile, 864 : of anus and 
scrotum, 382 ; of children, 220, pruriginous, 420, 
661; vulvar, 662, 987; 937, 982. 

Emmenagogue, 544, 578. 

Ergotine for hypodermatic injection, 420. 

Erysipelas, 343, 382, 506. 

Expectorants, 302, 662, 782. 

Expectoration, purulent, 590. 

Favus, treatment of, 262, 864. 

Feet, sweating, 982. 

Fever catarrhal, 419. 

Fever, typhoid, treatment of, 302. 

Fissures of the tongue, 96, 140. 

Gargle, 96, 500. 

Gastritis, acute, 343. 

Gastro-intestinal catarrh, infantile, 738. 

Glossitis, marginal exfoliative, 420, 782, 937. 

Glottis, spasm of, 430. 

Gonorrhoea, 96. 302, 408, 506. 

Gout, 24, 96, 699, 864. 

Grippe, hyposulphite of soda in, 644. 

Gums, bleeding, 982. 

Haematemesis, from gastric ulcer, 863. 

Haematochyluria, bichromate of potash in, 186. 

Haemoptysis, 382. 500, 826. 

Haemorrhage. 506, 864. 

Haemorrhoids, 186, 578, 900. 

Hair, falling out of, 262. 

Hair wash in seborrhcea capitis, 219. 

Headache, 57, 578, 981. 

Heart, irritable, 220, 662. 

Hemicrania, 981. 

Herpes praeputialis, 782. 

Hiccough, 505. 

Hives, 219, 

Hyperchloridia, 864. 

Hyperidrosis, 58, 782. 

Impotence, functional, 699. 

Incontinence of urine, 558, 700, 825. 

Influenza, 505, 506, 644, 982; camphor in, 661 ; colds, 
506, 

Insomnia, infantile, 96. 
Intestinal antisepsis, 577, 867. 
Iodoform, Prey's emulsion, 900. 
Irritable heart, 220. 

Itching of measles, scarlet fever, etc., 900, 

Jaundice, 344. 

Keely cure, 382. 

Kola essence, 544. 

Lanoline ointments, 578. 

Laryngeal affections, 140. 

Laryngitis, stridulous, 782. 

Laxative, 96. 

Leg ulcer, 863. 

Leucorrhoea, 700. 

Linseed oil emulsion, 578. 

Lupus erythematosus, 826. 

Lupus, facial, erythematous, 863. 

Malaria, 186. 

Matism, 220. 



Index, 



ix 



Meningitis, epidemic cerebro-spinal, 58. 

Menorrhagia, j)ainful, 826. 

Metrorrhagia, 738, 864. 

Milk substitute, 699. 

Mouth-wash, disinfectant, 661, 1014. 

Muscilage, 826. 

Nephritis, acute, 982 

Neuralgia, 24, 343, 344, 699, 825, 863, 937. 

Night-sweats, 577. 

Nipples, cracked, 24, 863. 

Odontalgia, 738. 

Ophthalmia, scrofulous, 662. 

Orchitis, 220. 

Os uteri, painless dilatation of, 220. 

Otalgia, J 86, 544 1013. 

Otitis, syphilitic, 140. 

Ottorrhoea, 826. 

Papoid in diphtheria, 302. 

Pedieuli pubis, 863. 

Pelada, 96. 

Peritonsillitis and tonsillitis, recurrent, 302, 

Pharyngitis, chronic, 24. 

Phthisis, cough, 1013. 

Piperidizine, 505. 

Pityriasis versicolor, 420. 

Plaster of Paris, 365. 

Pneumonia, grippal, 863; fibrous, 937. 

Powder, dusting, 58. 

Prurigo, 898. 

Pruritis, 982, 1013. 

Pruritis ani, 578. 

Pruritis. vulv£e, 420. 

Psoriasis, 938. 

Ptyriasis versicolor, 544. 

Purgative in children, 458. 

Purgative pill, 344. 

Quinine, for infants, 661; hypodermic injections of, 

343 : solution, palatable, 458. 
Rhachitis, 557. 

Rheumatism, 544, 900, 1004; and lumbago, 96. 

Rheumatoid arthritis, 220. 

Rhinitis, scrofulous, 570. 

Rickets, phosphorus in, 262. 

Ringworm, 186, 343. 

Roundworms in children, 220 

Salol as a coating for pills, 262. 

Scabies, 140, 344, 738. 

Sciatica, 24, 219. 

Scrofula, 262. 

Sea sickness, resorcin in, 699. 

Seborrhoea capitis, hair wash in, 219. 

Seminal emissions, 219. 

Shampoo, 662. 

Skin diseases, chronic, 577. 

Smallpox vesicles, to prevent pitting of, 96. 

Sore throat, 782, 

Stomatitis, in children, 220 ; mercurial, 506. 
Strychnine, in alcoholism, 220. 
Styrone, as a deodorant, 900. 
Sycosis, 826. 

t?yphilis, during pregnancy, treatment of, 58. 
Sweating hands, treatment of, 58. 
Tetanus, 343; traumatic, 826. 
Throat, sore, 458. 

Tonic, 544, 594, 699, 900, 937, 1013. 

Tonsillitis, acute, 382, 420: chronic, 863; rapid cure, 

262: and peritonsillitis, recurrent, 302. 
Tuberculosis, 139, 937. 
Tympanites, 738. 
Typhoid fever, 302, 577. 

Ulcers and gangrenous wounds, 343; chronic, fuchs- 

ine in, 140; varicose, 58. 
Uterine haemorrhage, hydrastin in, 864. 
Urticaria, antipyretics ia, 58. 
Vaginal catarrh, acute, 738. 
Vomiting, 24, 577. 
Vulva, eczema of, 262. 
Whooping-cough, 24, 220, 458, 544, 982. 
"Worms, round, in children, 220 ; seat, 680. 



Fraenkel, A., M. D.— Multiple neuritis, 281. 

Fractures and injuries of the spine, 49. 

Fracture of colles, 283: of the skull, compressed, treat- 
ment, 90 ; of shaft <>f the femur, treatment of, 314. 

Frank, Louis F. — Modern dermatology, 928. 

Franklinic current, physiological effects of, 745. 

Fraunfelter, Jas., M. D. — Acute rheumatism, 254. 

Frequency of infantile convulsions, 77. 

Frommel, R. — Treatment of extrauterine pregnancy, 
681. 

Galactagogue, 395. 
Galega as a galactagogue, 854, 395. 
Galvanic current in the treatment of intestinal occlu- 
sions, 229. 
Galvanism in pruritus vulvae, 555. 

Galvanization and faradization in treatment of uterine 

fibroids, 240. 
Gangrene following injections of antipyrine, 709. 
Gangrene of feet, symmetrical, 748. 
Gangrene, senile, treatment of, 65. 
Gastric fistula, 353. 

Gastro-enteritis in young children, subcutaneous injec- 
tion of saline water in, 876. 
Gastro-intestinal haemorrhage in the new-born, 556. 
Gastrolith in man, 429. 

Gastrostomy in cancerous stenosis of the cardiac orifice 
of stomach, 710 ; in stricture of the oesophagus, 672; 
the stomach after, 991. 

Gelatin discs, use in the eye, 686. 

Germination, induced by microbes, 797. 

Gestation, extra uterine, 354. 

Girls, examination of young, 761. 

Glands, inguinal, removal, 1012. 

Glaucoma, double subacute, 709. 

Gleet and bubo. 403. 

Glucose as a diuretic, 988. 

Glycerine for burns, 189, 310. 

Glycosuria and azoturia after extirpation of the pan- 
creas, 468 ; and locomotor ataxia, 948. 

Goitre, pathology, diagnosis and treatment, 68 ; stro- 
phanthus in, 870 ; osmic acid in, 64; sixty-two cases 
of enucleation for, 231; treatment of, 353. 

Gonorrhoea, extension of to the pars posterior urethrae, 
time and cause of, 74 ; in the female, 35 ; stomatitis 
in an infant, 77: salicylate of mercury in, 466 ; 
periurethral abscesses in, 708 ; systemic infection, 
938. 

Gonorrhoeal rashes, 749. 

Goodell, William, M. D. — Incomplete laparotomy with 

injury to bladder, 724. 
Grafts, tendon, 576; damages for lost, 920. 
Gravidarum, hyperemesis, astiology of, 316 ; ptyalism 

and hysteria, 76 ; tetiology of, 316. 
Griffith, J. P., M. D. — Colorado Springs in the climatic 

treatment of phthisis, 15. 
Grippe, cardiac, 561; cardio-vascular, 801 ; treatment, 

789 ; creasote in, 986. 
Grippal pneumonia, 601. 
Growing fever, 758. 
Guaiacol, carbonate, 999. 
Gum arable, substitute for, 597. 
Gut, silk-worm, in surgury, 949 
Gumma of the iris, 178. 

Gynaecology and obstetrics, present status, 966. 
Gyngecology, a year's work in minor, 611 ; heroic, 236 ; 
use of actual cautery in, 474. 

Haematoma after labor, 951. 

Haematoma, puerperal, under Douglass pouch, 914. 

Hematuria and oxaluria, 31. 

Haemoglobin and spleen, cells of, 150. 

Haemoglobin, therapeutic value of, 744. 

Haemol and hgemogallol, 639. 

Haemophilias, 999. 

Haemoptysis, treatment of, 63. 

Haemostatic, cornutin as, in heemorrhages from the 
bladder and female genitals, 103. 



X 



Index. 



Hsemorrhage, basal, successful trephining, 590 ; visce- 
ral, in stillborn children, 196. 317; after tonsillot- 
omy, getiology prophylaxis and therapeutics of, 230 ; 
intracranial, operation, 393 ; uterine, hydrastin in, 
701; intraperitoneal, 613; from scarification of con- 
junctiva, 559 ; saline infusion in, 707 ; postpartum, 
652; postpartum, iodoform gauze in, 507. 

Haemorrhoids, 923 ; antiseptic treatment of, 705 ; 
treated by injections of carbolic acid, 817. 

Haggard, W. D., M. D. — Play of shoulders in produc- 
ducing laceration of the perineum, 251. 

Hallum, J. W., M, D. — Haemorrhoids treated by injec- 
tions of carbolic acid, 817. 

Hamilton, John B., M. D.— Surgical clinic, 401, 921. 

Hands, disinfection of, 435. 

Hanging, death by, 479. 

Harris, Robert P. — Tocci brothers of Locana, Italy, 
887. 

Hasencamp, 0. — Treatment of orchitis and epididy- 
mitis, 1006. 

Headache, treatment of, of gastric origin, 266; reflex, 
727. 

Heart disease, pain in, 151 ; disease, pregnancy and, 76. 

Heart, primary tumors of, 226. 

Heising, A. F. — Scarlet fever, 542. 

Helferich, Prof. — Treatment of severe phlegmons, 441. 

Helinin in leucorrhoea, 356, 435. 

Hemeralopia, antipyrine in, 691. . . 

Hemiatrophy, facial, 191, 311. 

Hemihypertrophy, 851. 

Hemiplegia, 523. 

Hepatic colics, antipyrine in, 389. 

Hernia, resection of gangrenous bowel for incarcerated 
inguinal, 471 ; treatment by injection of alcohol, 792 ; 
strangulated, local application of ether in, 232 ; 
strangulated, statistics of 85 operations, 712 ; ingui- 
nal, radical cure, 521; scrotal, 570; scientific cure, 
571; reducible, treatment of, by alcoholic injections, 
151. 

Herrick, J. B., M. D. — Sarcoma of the kidney, 258. 

Hiccough relieved by lavage of the stomach, 427. 

Hip-joint diseases, pathology of, 203 ; during child- 
hood, 286, 326; operative treatment, 591, 644. 

Hirsch, A-. B. — Scrotal hernia, 570. 

Histories and summaries of cases, 169. 

Homatropine discs in refraction, 931. 

Huchard, H. — Cardiac grippe, 561 ; grippal pneum<)nia, 
601; Cardio-vascular grippe, 801. 

Hunter, Wm. — Phagocytosis, 526. 

Human race, mortality of, 400. 

Hutinel, Dr. — Cold-bath in broncho-pneumonias, 960. 

Hydropathy in the treatment of diphtheria, 103. 

Hydatid cysts, of the lungs, 909 ; of the brain, 1. 

Hydatids in the pelvis stimulating ovarian tumor, 114. 

Hydatiform mole, 636. 

Hydrastinin, 836 ; in metrorrhagia, 76. 

Hydrastin in uterine hgemorrhage, 701. 

Hydrastis canadensis in obstetrics, 234. 

Hydrate of amylene in epilepsy, 268. 

Hydrazoic acid, 597. 

Hydrocele, cure by excision of sac, 430 ; treatment, 672. 
Hydrocephalus, chronic, 711. 

Hydrogen peroxide, 500 ; antiseptic properties, 667 ; 
test for, 680 ; in eye diseases, 870 ; treatment of 
fistulae by, 90 ; as a disinfectant of water, 936. 

Hyoscine as a hypnotic in the insane, 653, 869, 904. 

Hyoscyamine, as a hypnotic, 904; in lettuce, 558. 

Hyperemesis gravidarium, ptyalism and hysteria, 76, 

Hypnotic action of the antipyretics, 102. 

Hypnotic suggestion. Onanism cured by, 666. 

Hypnotics, their use among the insane, 901. 

Hypnotism, 107 ; legal restrictions, 957. 

Hypnotism and electro-magnetism, 749. 

Hysterectomy, supra-vaginal, 53 ; vaginal, for carci- 
noma, 235 ; for carcinoma of uterus, 915. 

Hysteropexie, new method, 616. . 

Hysterorrapby, modified, 9.14. 

Hysteria, in children, two cases, 676 ; in infants and 
children under 2 years, 357 ; syphilitic, 392. 



Ichthyol, 787; in pyrosis, 146; in gynaecological prac- 
tice, 240, 594 ; new observations of therapeutic 
actions, 907. 

Icterus in the new-born, 594. 

Igni puncture, value of, in treatment of hypertrophied 

cervix uteri, 75. 
Ileo-colostomy, 952. 

Ilium, fracture of anterior superior process of, 980. 
Ileus, olive oil in large doses, 510. 
Importance of blood-clot in treating dead spaces, 45. 
Impotence in men, treatment, 788. 

Impregnation from semen deposited on the vulvae, 273. 

Inebriety, inherited, prophylgixis, 718. 

Infant mortality in France, 677. 

Infants, artificial feeding, 616. 

Infectious diseases and endometritis, 515. 

Influence of diseases upon the respiratory interchange 
of gases, 108. 

Influenza, abroad, 160 ; chloride of ammonium in, 103 : 
cerebral disturbances following, 887 ; and neuroses, 
708; bacillus, 244 ; epidemic; re-appearance of, 270; 
laryngeal paresis after, 312 ; nervous and mental 
phenomena as sequela? of, 297 ; vaccination as a 
prophylactic against, 198 ; speedy cure of, 348 ; in- 
sanity, 352 ; epidemic, 445 ; and pelvic cellulitis, 
474 ; infectiousness of, 391 ; influence on the death- 
rate, 638 ; eye lotions of boric acid in, 558 ; prophy- 
laxis and treatment, 649 ; treatment of, 308, 906 ; coca 
as a prophylactic against, 144; quinine as a prophy- 
lactic, 956. 

Inhalation, oxygen, 30. 

Inhalations of ozone in treatment of whooping-cough, 
275. 

Injection of ether after abortion, 316. 

Insane, acetonuria in the,238 ; blood and urine in, 406 ; 

hyoscine in, 633 ; urine toxicity of, 679. 
Insanity, alleged increase, 769 ; an excuse for adultery, 

520 : and typhoid fever, 311; influenzal, 352. 
Instruments, metal, sterilization of, 149. 
InsuflSation, happy application of, 704. 
International Congress of Syphilis and Prostitution, 

439. 

International Dermatology Congress, 200. 
International Gynaecological and Obstetrical Congress, 

520, 560. 
Intestinal anastomosis, 565. 

Intestinal obstruction, treatment of, 269 ; from 
MeckePs diverticulum, 471; due to round worms, 512. 

Intestine, nerve supply of, 191 ; submucous resection 
of, 34 ; pathology of nerve-plexuses, 791. 

Intravenous saline infusion, 667. 

Intubation, and tracheotomy, 795 ; of the larynx, 436 ; 

in croup, 117; in Russia, 656; in 1890-91, 156. 
Inversion of non-puerperal uterus, 135. 
Iodine water and aristol as surgical antiseptics, 73, 

438. 
lodism, 268. 

Iodoform as a prophylactic in ophthalmia neonatorum, 
916. 

lodofrom gauze in postpartum haemorrhage, 507. 

Iodoform sponges, 708. 

lodol, therapeutic uses, 663. 

lodo-naphthol, 519. 

Ipecacuanha in anthrax, 224. 

Irrigation, intra-uterine, after labor, 197. 

Iris, gumma of, 178. 

Iritis, aetiology, 885. 

Iron, glycerite of, 839. 

Isopathy, 600. 

Itching, aetiology, 946. 

Jaborandi for urticaria, 224. 

Jackson, Edward, M. D. — Simple extraction of cata- 
ract, 88. 

Jambul in diabetes mellitis, 745.' 

Jefferson Medical College, new buildings, 479. 

Jenkins, R. J., M. D. — Surgical knowledge in general 

practice, 291. 
Jewett, Chas., M. D.— Caesarian section, 453. 



Index. 



xi 



Kanthack, A. A. — Phagocytosig, 497. 

Kelly, E. B. P., M. D.— Obituary, 26. 

Kerauno-neuroses, 108. 

Keyser, P. D., M. D.— Pterygium, 123. 

Kidney, abscess of, SS2 : changes of. in phthisis. 149; 
disease with cardiac complications, 92; extirpation 
of tuberculous, 6S6; sarcoma of, 258; gun-shot 
wound, 977. 

Kinnicutt, Francis P. — Prophylaxis and treatment of 
tuberculosis, S44. 

Kirkpatrick, A. B., M. D. — Medical treatment of ap- 
pendicitis, 84. 

Kitasato, S., M. D. — Influenza bncillus, 245. 

Klein, E. — Phagocytosis, 496; remarks on influenza 
bacillus. 

Kneipp's water cure, 146. 

Koch's remedy in minute doses, further results from, 
224. 

Koenig, Adolph, M. D. — Pneumonia, 651. 

Kola, purified, 998. 

Konig, Franz. — Haemophilias, 999. 

Labor, cutaneous emphysema during, 592; induction 
of by injections of glycerine, 674; premature, caused 
by multiple arthritis, 755 ; hymen obstructing, 914 ; 
pains, weak in old primiparaj, 516. 

Labors, results of, 200, without internal disinfection, 
913. 

Lactation, temporary, blindness during, 433. 

Lactic acid in diarrhoea, 427. 

Lactose and glucose as diuretics, 988 

La Grippe, 40 : effects of on mind and nervous system, 

303: specific for, 172; [See Influenza.] 
Laparotomy for wounds of liver, 73 : incomplete, with 

injury to the bladder, 724 ; in peritonitis, 115; under 

cocaine, 715. 

Laparotomies, remarks on series of one hundred, 75. 
Lard, test, 639. 

Laryngeal croup, etherization in, 317. 

Laryngeal obstruction from milk curd, death, 864. 

Larangeal paresis after influenza, 312. 

Larynx and pharynx, antipyrin in the affections of, 31. 

Larynx, fractures of, 635. 

Lavage, of stomach for hiccough, 427 , in vomiting 

following chloroform, 29. 
Law suit, curious, 799. 

Leading Articles: 

Abdominal palpation and pelvimetry, necessity for 

the more general use in obstetrical practise, 24. 
Basedow's disease, treatment, 422. 
Chloralamide as a hypnotic, 383. 
Cholera, Asiatic, recent investigations, 459. 
Chorea and epilepsy, relation, 629. 
Chromic acid in syphilitic affections of the mouth, 346. 
Cough, phthisical, treatment, 187. 
Defcecation, oral, 940. 
Digestive disturbances in childhood, 1015 
Diphtheria, peroxide of hydrogen in, 59. 
Electrotherapy, 263. 
Endometritis, treatment, 739. 
Enuresis, nocturnal, manual treatment, 827. 
Epilepsy and chorea, relation, 629. 
Epilepsy, unusual manifestations of, 221. 
Ergot as a hfemostatic in uterine haemorrhage, 141, 
Grip, effects on the mind and nervous system, 303, 
Haemorrhage, post-partum, iodoform tampon in, 507. 
HEemorrhage, uterine, hydrastine in. 701. 
Hydrastine in uterine haemorrhage, 701. 
Hydrogen peroxide in the treatment of diphtheria, 69. 
Hypnotics, use among the insane, 901. 
Insane, use of hypnotics among, 901. 
lodol, therapeutics, 663. 

Iodoform gauze tampon in post-partum hsemorrhage, 
507. 

Leprosy, infectiousness, contagiousness and heredity 

of, 545. 
Lysol in gynaecology, 983. 

Massage, value histologically demonstrated, 741. 



Mental disease, neurasthenia in relation to, 97. 
' Neurasthenia and its relation to mental disease, 97. 
Ophthalmia, contagious, prevention of blindness from, 
783. 

Oral defalcation, 940. 

Pental as an antesthetic in surgery, 939. 

Pleuritis, aetiology, 865. 

Pregnancy, shall the uterine adnexa be removed to 
prevent, 421. 

Syphilitic affections of the mouth, chromic acid in, 346 
Tumenol, 345. 

Typhus fever in New York and North Brother Is- 
lands, 579. 

Uterine adnexa, shall they be removed to prevent 

pregnancy, 421. 
Uterine haemorrhage, ergot in, 141. 
Visiting Nurse Society of Philadelphia, 142. 

Lead poisoning from paper hanging, 717. 
Lead poisoning, ulceration of the mouth as a symptom 
of, 227. 

Leprosy, 545, 648, 948; and fish diet, 918; chalmoogra 

oil in, 906 ; in Japan, 880 ; tuberculin in, 744. 
Lettuce, hyoscyamine in, 558. 

Leucocytes, behavior in immune animals to toxines, 

494; in pneumonia, 671. 
Leucorrhcea, helenine in, 356, 435. 
Leukgemia acutissima, 428. 

Lewis, G. C, M.D.— My last 100 obstetric cases, 294. 
Life of various animals, duration of, 520. 
Ligation of femoral artery, 882. 
Light, a new and powerful, 600. 
Limping, treatment of causes, 431. 
Linaraarin, 39. 

Lindner, Prof. — Myositis, 481. 

Linseed oil emulsion as a substitute for cod-liver oil, 747. 
Linville, Mont, M. D. — Importance of blood-clot in 

treating dead spaces, 45. 
Lipoma of the tube, 434. 

Listerine, spirits of thymolini-compositus, 272. 
List of medical journals, 240. 

Lithotrity in boys, 475; in women, difficulty, 556. 
Liver, antiseptic functions of, 791. 

Liver, extirpation of, results of, 313 ; laparotomy for 

wounds of, 73 ; malignant tumor of, 923; sterility 

and hydatid disease, 995. 
Liver, surgery of^ 895. 
Locomotor ataxia and glycosuria, 948. 
Loomis,, Alfred — Alcoholic pneumonia, 959. 
Luckjauow on the pathology of the cell, 215. 
Lungs, syphilitic disease of the, 32 ; gangrene, surgical 

treatment, 992. 
Lupus, a remarkable complication of, 193 ; tuberculin 

in the treatment of, 29; treatment, 987 ; treatment by 

excision, 993. 

Luxations, of thumb, irreducible, treatment, 470 ; old, 
arthrotomy in, 70. 

Lydston, G. Frank, M. D — Surgical pyelitis, 161 ; al- 
leged syphilitic infection by instruments, 805. 

Lysol in gynaecology and obstetrics, 983. 

MacDonald, Arthur — Ideas of Luckjanow on the path- 
ology of the cell, 215. 
Macrophages, 489. 

Magnesia sulphate in epithelioma, 467. 
Malarial fevers, irregular, parasite of, 749. 
Malarial poisoning, treatment with chinchonidine, 942. 
Malaria, methylene blue in, 746; phenocoll hydrochlo- 
ride in, 29. 
Male fern, extract of, 944. 

Mammge, abnormal and supernumerary, 390 ; one or 

two? 433. 
Man, what constitutes, 439. 

Manley, Thos., M. D. — Diseases of hip during child- 
hood, 286, 326. 

Mann, M. D., M. D, — Chronic pelvic peritonitis, 44. 

Mansfield, Arthur D., M. D. — Episcleritis, 449; homa- 
tropine discs in refraction, 931. 

Martin and Crawford — Ovariotomy, 541. 



xii 



Index. 



Martin, Sidney — Phagocytosis, 533. 

Massage, in the treatment of pleuritic exudation, 511 : 

infantile, 470 ; Japanese. 704: pelvic, 515: of the 

prostate, 511 ; technique of, 145 ; value histologically 

demonstrated, 741. 
Massey, G. B. — Electro-gvnaecology, 323; metritis, 

409. 

Mastoid process, disease of, 770. 
^Maternal impressions. 394. 
Mathew Duncan memorial, 280. 
Matrimonial sterility, 641. 

Mayo. Florence, M. D — Gumma of the iris, 178. 
McBurney, Chas. — Clinical Lecture, 881. 
McCann, Jas. — Sarcoma of mesentery and resection, 
501. 

McGirk, John D. — Specific for La Grippe, 172. 
Measles, bacillus of. 876. 
Mediastinitis, acute, 90S. 
Medical legislation in Ohio, 119. 
Medical proverbs, 64 0. 
Medical reading parties, 720. 
Medical treatment of appendicitis, 84. 
Medicated soaps, 787. 

Medico-Chirurgical College of Philadelphia, 999. 

Meniere's vertigo and semicircular canals, 67. 

Menstruation, after removal of the ovaries, 674; and 
lactation, 473: in a child, 996. 

Mental degeneration, systemized delusions in, 147. 

Menthol in pruriginous afTections of skin, " 666; in 
pruritis vulvae, 675. 

Mercurial ointment, determination of quantity of mer- 
cury, 879. 

Mercury nitrate as a caustic, 667. 

Mercury salts and iodine compounds, 798. 

Mesentery, removal of sarcoma of, 110. 

Methods of carrying out asepsis in Von Bergman's 
clinic, 230. 

Method for grafting ulcers, 73. 

Method, new, of estimating urea, 359. 

Methyl blue and methylene blue, 639. 

Methylene blue as an antiperiodic, 388. 

Methyl violet in affections of air passages, 425. 

Metritis treated by electricity, 409. 

Metrorrhagia, 755 ; electricity in, 235 • hydrastinin in, 
76. 

Metschinikoff's researches on phagocytosis, 488. 
Microbes and germination, 797. 
Microbes of the Dead Sea, 678. 

Microorganism in the blood of influenza patients, 246. 
Microorganisms eliminated by the sweat, 917. 
Microphages. 489. 

Midwifery, practical teaching of, 799. 

Milk, condensed, improved process for, 279. 

Milk, origin of citric acid in, 428. 

Milk secretion, antipyrine to dry up, 593. 

Milk, sugar in milk, estimation of, 279. 

Mills, Chas. K., M. D. — Nervous and mental phenom- 
ena and sequelae of influenza, 207. 

Mississippi Valley Medical Association, 679. 

Mode of cultivating influenza bacillus, 245. 

Modern renal surgery. 71. 

Molluscum fibrosum, 847. 

Montgomery, E. E. — Clinical lecture, 484. 

Moore, C. C'. — Treatment of diphtheria, 973. 

Morbid changes in joints in syringomyelia, 120. 

Morphine, as a hypnotic, 904; detection in urine, 519. 

Morphinomaniacs and hypodermic syringes, 560. 

Morphology of breast milk and the nutrition of the 
child, 117. 

Mortality of the human race, 400. 

Mouthwash for carious teeth, 63. 

Movable viscera, 225. 

Multiple neuritis, 281; puerperium as a causative fac- 
tor, 636. 
Muscles, ocular, 352. 

Mussels, urticaria of throat from eating, 468. 
Mynter, Herman — Case of crushed kidney, 933. 
Myositis, 481 ; ossifying, 512. 
Myrtol, 477. 



Xaphthalin in whooping cough, 274, 595. 

Kasal fossEe, fibrosarcoma of, 675. 

Nasal septum, fracture of, 729. 

Nascentium, trismus, sulf'inal in, 120. 

Nephrectomy, transperitoneal, 993. 

Nephritis, acute parenchymatous, 502: and albumi- 

naria, treatment of, in pregnancy, 112: latent, 454; 

new variety, 669 : scarlatinous, prophylaxis, 676. 
Nerve-grafting, 911. 

Nerve-stretching in the treatment of perforating ulcer, 
890 ; in tic douloureux, 393 ; therapeutic value of, 31. 
Nerve supply of the intestines, 191. 
Nerves, suturing of, 74, 711. 

Nervous and mental phenomena and sequelae of in- 
fluenza., 207. 
Nervous system and alcohol, 116. 

Neuralgia, methylene blue in, 736 : trigeminal, various 

surgical procedures for cure, 793. 
Neurasthenia and changes in gastro-intestinal tube, 

669: and its relations to mental diseases, 97; and 

varicocele, 552 ; artificial, 67 : injections of infusions 

of nervous tissue in, 943. 
Neuritis, alcoholic, 351 ; multiple, 281; peripheral, in 

cancer. 392. 
Neurology, modern, 1005. 

Neuroses, and influenza, 703 ; and neuro-psyehoses 
after trauma, 589. 

Newborn, obstetrical paralysis in, 113. 

New Jersey State Medical Society, 905. 

Nitroglycerine, subcutaneously in poisoning by illum- 
inating gas, 194; in asphyxia, 1018. 

Nitrous ether and astringent drugs, 678. 

Noble, Chas. P. — Minor gynaecological surgery, 611. 

Nocturnal enuresis in mouth-breathers, 117 ; manual 
treatment, 827. 

North Brother Island Hospitals, management, 920. 

Nose and throat, pathological conditions of, as causal 
factors in asthma, 166. 

Nursing bottle, 876. 

Obstetrical bundle, 834. 

Obstetric cases, last, 100, 294. 

Obstetric paralysis in the newborn, 113. 

Obstetric practice : the necessity for the more general 

use of abdominal palpation and pelvimetry, 25. 
Obstetrics and gynjecology, present status, 966. 
Obstetrics, chloroform in, 592 ; hydrastis canadensis 

in, 234; tobacco in, 272. 
Obesity, 919 ; influence of, on female sexual functions, 

316. 

Ocular muscles, 352. 

Ocular paralysis, recurring, 792. 

(Esophagus, diverticulum, 822. 

(Edema as a symptom occurring in malignant dis- 
eases, 81. 

Olive oil in large doses in ileus, 510 ; detection of pea- 
nut oil in, 437. 

Onanism cured by hypnotic suggestion, 666. 

Oophoritis, acute, complicating pregnancy, 515, 636. 

Ophthalmia neonatorum, iodoform as a prophylactic, 
916 ; as a cause of blindness, 129. 

Ophthalmia, prevention of contagious, 783. 

Opiates, conti;aindications for use of, 368. 

Opium, alkaloidal variability of, 558 • disease, new 
studies of, 372 ; enemata in threatened abortion, 112; 
tincture, improved, 719; belladonna and chloral pois- 
oning, 971; strychnine as an antidote, 986. 

Opticians, prescribing, 480. 

Optic lobes, diagnosis of lesions of, 792. 

Orexin, action pf, on the stomach, 179, 309; 

Organs, of hearing and life insurance, 126. 

Osmic acid in goitre, 64. 

Ostitis, of hip, 608 : suppurative after tamponing, 647. 
Ovarian cystoma, 339. 

Ovaries, incomplete removal of diseased, 274; removal 
of for mollities ossium in non-puerperal women, 680. 

Ovariotomy, 541 ; in a patient in her eighty-second 
year, 953. 

Ovaritis, chronic, treatment, 396. 



Index. 



xiii 



Ovary and tube, supernumerary, 915; colossal fibro- 

systoma of, 915 ; papillary cystoma, 515. 
Ovulation without menstruation ; pregnancy, 675, 
Oxaluria and baeraaturia, 31. 

Oxygen inhalation, 30; pure, to obtain rapidly, 158. 
OzEsna, radical cure for, 111 ; treatment of, 267. 
Ozone, inhalations of, in whooping cough, 275. 

Pains of central origin, 351. 

Packard, Jno., M. D. — Supra-public cystotomy, 321. 
Palate, cleft, operation for, 314. 

Palmer, C. D. — Present status of obstetrics and gynaec- 
ology, 966. 

Pancreas, glycosuria and azoturia after extirpation, 
468. 

Pancreatic diabetes, 751. 

Pan-American Medical Congress, 238, 400, 598. 
Papoid in diphtheria, 756. 

Paracentesis abdominis, seat of puncture in, 112. 
ParafiBne in diphtheria, 236. 

Parasite, of irregular malarial fevers, 749 ; rare, 589 
Parasitical plants, action of on their hosts, 319. 
Paraldehyde as a hypnotic, 903. 
Paralysis, Brown-Sequard's, 470. 

Paralysis, obstetrical, in newborn, 113 ; operative 
treatment of deformities resulting from infantile 
spinal and cerebral spastic, 872 ; post-diphtheritic, • 
853 ; spastic infantile spinal, 108 ; general, symp- 
tomatology, 1006; posticus, in infants, 955. 

Paramyotonia, ataxic, 945. 

Paresis, laryngeal, after influenza, 312. 

Park, Roswell, M. D.— Clinical Lecture, 684. 

Park, Roswell, M. D. — Colles fracture, 283. 

Parturition, air in, 273; does organic heart disease 
preclude the use of chloroform in ?, 811. 

Pastuerism in Milan, 799. 

Pasteur Institute of New York, 879. 

Pasteur Institute, statistics, 904. 

Patella, fracture, 969. 

Pathology of hip-joint diseases, 203. 

Pathology of the cell, Luckjanow on, 215. 

Patton, Joseph M., M. D.,— Kidney disease with car- 
diac complications, 92. 

Peary Relief Expedition, surgeon wanted, 999. 

Pediculosis, benzine in, 268. 

Pelvic cellulitis and influenza, 474; inflammation, 636; 
effects on pregnancy and childbed, 874 ; a pathologi- 
cal study, 593 ; reflex troubles, 820. 

Pelvis, partial starvation of foetus in contractio of, 
794; mechanism of fractures of, 473. 

Pemphigus, 837. 

Pennsylvania State Medical Society, 720. 

Pental : new anaesthetic, 193 ; as an anaesthetic, 939; 

in surgical practice, 948. 
Pepsin standard advanced, 829. 

Peptones, dietetic value of, 157; quantitive estimation, 
399. , 

Perdue, H. — Treatment of pneumonia, 1007. 

Perineum, play of shoulders in producing laceration of, 
251 ; protection of, 233. 

Peritonitis, 173; cocaine in, 348 ; chronic in children, 
757; chronic pelvic, 44 ; laparotomy in, 115; puer- 
peral, treated by amputation of the uterus, 616 ; 
tubercular in children, surgical treatment, 836 ; puer- 
peral, treated by hysterectomy, 977. 

Perityphlitis, case, 936. 

Peroxide of hydrogen, 500 ; in typhoid fever, 224; in 

diptheria, 59. [See Hydrogen peroxide.] 
Peter, Prof. — Treatment of pleurisy, 924. 
Pertussis, 837 ; cocaine in, 236. 
Pessary worn for twenty years, 795. 
Pets, dangerous, 640. 

PfieflFer, R., M. D.— Influenza bacillus, 244. 
Phagocytosis, 487, 525 ; and immunity, 617 ; and poison 

theory, 832 ; the debate on, 640. 
Pharynx and larynx, antipyrin in aflFections of, 31. 
Phenacetine, as an antipyretic, 708 ; identity reaction 

of, 319, 798; differentiation from other antipyretics, 

999. 



PhenocuU hydrochloride in malaria, 29. 
Philadelphia Polyclinic, 680, 920. 
Phimosis, congenital, 401. 
Phlebitis, suppurative, treatment, 591. 
Phlegmons, severe, treatment, 441. 

Phosphorus, potassium permanganate as an antidote, 

707 ; poisoning, 988. 
Phthisis, changes of the kidney in, 149 ; new remedy 

for, 145; laryngeal, resorcin in, 28; laryngeal, 

tuberculin in, 66. 
Physical signs, value of, at the apices of the lungs in 

supposed incipient phthisis, 148. 
Physicians as sales agents for patent medicines, 809. 
Physicians do not write, 880. 
Physicians in Canada. 480. 
Physostigmine, salicylate of, 798. 

Pilocarpine, in puerperal eclampsia, 113; for dryness 
of tongue, 267. 

Piperazine, observations on the use of, 105; therapeu- 
tic application, 869. 

Placenta, deciduo-sarcoma of, 912; trilobed, 514. 

Plants, narcotic, alkaloidal assay of, 158; parasitical, 
action of on their hosts, 319. 

Plastic operations and tumors treated by overheating 
the' tissues, 390. 

Pleurisy, antiphlogistic method of treatment, 924. 

Pleurisy with efi"usion, salicylate of soda in, 426. 

Pleuritic exudation treated by massage, 511 ; aetiology, 
865 ; salicylate of soda in, 987. 

Pneumatic soles, 318. 

Pneumococus, its toxines and immunity 398. 

Pneumonia, alcoholic, 959; croupous, 944; grippal, 
601 ; in children, temperature, 676 ; in children, 
treatment, 716; number of leucocytes in blood, 671 ; 
production of immunity against and the cure of, 
227; treatment, 650, 687, 730, 765, 824, 944, 1007; 
treatment of in diabetics, 64. 

Podophylotoxine, 428. 

Polypharmacy, 480. 

Polypi, nasal, radical treatment, 950. 

Porrigo, contagious, epidemic in infants, 676, 

Porro operation, 993. 

Porro's operation, 754. 

Post-partum haemorrhage, treatment of, by means of the 
Duhrssen uterine tampon, 37. 

Potsdamer, Joseph B., A. M., M. D. — Vin. lodinii 
comp. in the treatment of catarrhal afiiections of the 
air passages, 21. 

Potasd, iodide of, in urticaria, 318. 

Powders, determination of specific gravity, 957. 

Pregnancy, acute oophoritis complicating, 636 ; amau- 
rosis and albuminuria of, 592 ; and heart diseait, 
76; early detection of, 434; influence of epilepsy, 
715; operative treatment of extrauterine, 681 ; pre- 
vention of by removal of the uterine adnexa, 421 ; 
retroflexion and retroversion, 914; some points con- 
cerning vomiting of, 133 ; theraphy in albuminuria 
and nephritis of, 474; to determine, 234 ; twin, with 
peculiar disposition of the ova, 874; hydatiform- 
mole, 952. 

Prehistoric trephining, 832. 

Prengrueber, Prof. — Inguinal hernia, 621. 

Prescription, 360. 

Prescription and the Geneva chemists, 715. 
Profession, how to improve the position of, 478. 
Prolapsis uteri, 484 ; treatment of, 235. 
Proprietary remedies, 520. 

Prostate, and bladder, operations on, 34; enlarged, 

operative relief, 613; massage of, 511. 
Prostatic hypertrophy, radical treatment, 714 ; 993. 
Prostatitis, chronic, suppositories, 615. 
Proteids, pathology of, 561. 
Proverbs, medical, 640. 

Pruriginous affections of the skin, methol in, 666. 
Prurigo in childbed, 273. 

Pruritus vulvae, galvanism in, 555 ; methol in, 676. 
Prince, J. A. — Abdominal section, afteritreatment, 692. 
Psoriasis urticaria and sycosis, 241. 
Pterygium, 123. 



xiv 



Index. 



Ptomaines, to extract from the urine, 438. 

Ptosis, congenital, new operation, 949, 978. 

Puerperal eclampsia, pilocarpine in, 113 ; subcutaneous 

injections of ether in, 197. 
Puerperal endometritis, histological study of, 315. 
Puerperal patient, posture of, 713. 
Puerperal septicaemia due to mephitic air, 834. 
Puerperal tetanus, 564. 

Puerperium as a factor in multiple neuritis, 636. 

Pulmonary gangrene, 388. 

Pyelitis, surgical, 161. 

Pyoktanin in ophthalmic practice, 501. 

Pyrexia and antipyrexia, 271. 

Pyrosis, ichthyol in, 146. 

Quackery, prize offered for essay on, 958. 
Quinine as a remedy for whooping-cough, 3c7. 
Quinine barks, estimation of total alkaloids, 598. 
Quinine hydrochlorate, 719. 
Quinine, indications for, 585. 
Quinine poisoning, 64. 
Quinine, safe, 518. 

Rancidification, phenomena of, 759. 
Recurrent peritonitis, 819. 
Rectum, stricture; colotomy, 922. 

Renal circulation and albuminuria, relations between, 
150. 

Renal surgery, modern, 354. 
Resection of the skull in traumatic epilepsy, 71. 
Resection of the spine for spondylitic paralysis, 153. 
Resorcin in laryngeal f^'hthisis, 28. 

Respiratory interchange of gases, influence of diseases 
upon, 108. 

Respiratory troubles, oxygen and strychnine in, 667. 
Re-vaccination in children, results in, 357. 
Reynaud's disease, nitroglycerine in, 747. 
Rhachitis, infectious origin, 997. 

Rheumatism, acute, 254 ; acute, confined to the tem- 
poro-maxillary joint, 192 ; nodose, in children, 595; 
in children, 517; cHironic, mechanical treatment, 855; 
remedy for, 425. 

Rhinitis, scrofulous, 570. 

Rickets, congenital, 916. 

Rigorous experiment, 679. 

Ringworm, 145 ; treatment, 989. 

Riviera, Americans in, 80. 

Roberts, John B., M. D. — Brain surgery, 5 ; disease of 
stomach, 405 ; inversion of a non-puerperal uterus, 
135. 

Roser's observations on phagocytosis, 488. 

Ross, Alice McLean. — Treatment of summer diarrhoea in 

children, 1004. 
Rubber foot fever, 280. 
Ruffer, M. Armand. — Phagacytosis, 617. 
Rush Medical College Concourse, 400. 

Salicylamide, 239, 

Salicylate of soda in pleuritic effusion, 426. 

Salicylic acid reaction, 678, 760 ; as a preventive of 
scarlet fever, 436. 

Salol, camphorated, in diseases of middle ear, 309 ; 
color reaction for, 199. 

Sanderson, E. Burdon. — Phagocytosis, 496, 

Sanitary triumphs, 38. 

Santoninoxyme, a new anthelmintic, 397. 

Sarcoma of the kidney, 258; of mesentery, 501; re- 
moval of, of the mesentery, 110. 

Sauerkraut in dyspepsia, 632. 

Scalds and burns, 337. 

Scarlet fever and diphtheria, non-identity, 516 ; relapse 
and recrudescence, 916; salicylic acid as a preventive, 
436 ; the tongue in, 837. 

Scarlatina, treatment, 954. 

Scarlatinous angina, clinical and bacteriological study 
of, 38. 

Scarlatina^ and diphtheria, hypodernaic injection of cor- 
rosive sublimate in, 63i 
Scarlatina, tu hasten desquamation in, 310, 



Scleroderma, 33. 

Schweinitz, Geo, E. De — Obstructive diseases of the 
lachrymal passages, etc., 688. 

Sclerosis, disseminated, 752. 

Scrofuloderma and lupus, treatment, 987. 

Scurvy, blood in, 671; in children, 996. 

Schneideman, T. B., M. D. — Ophthalmia Neona- 
torum as a cause of blindness, 129. 

Scoliosis, pathogenesis and treatment, 512. 

Seat worms, 717. 

Seligman, L., matrimonial sterility, 641. 
Septicaemia from a putrid foetus, 636. 
Sensibility, return of after 14 year's loss, 428. 
Sex, forecasting before birth, 395. 

Sexual organs of child, case of too early development, ■ 
916. 

Shaffer, J. M., M. D. — A case of diabetic coma, 297. 
Shimwell, B. T.— Hernia, 571. 
Silk- worm gut in surgery, 949. 

Simon, Jules, M. D. — Treatment of typhoid fever in 
children, 41. 

Sinuses, maxillary and frontal, illumination versus 

puncture of, 225. 
Sixth nerve, bilateral paralysis of, 588. 
Skin diseases, drying liniment in, 706. 
Skin grafting, Thiersch's method, 881. 
Skin, lymph tracts and circulation of, 390. 
Skin, vascular territory of, 965. 

Skull, bullet in for forty years, 709 ; fracture and 
trephining, 540; resection of, in traumatic epilepsy; 
71 ; fracture of, 921: case of depressed fracture, 950. 

Smith, A. A., M. D. — Gun shot wound of stomach, 770. 

Smith, Henry R., M. D. — Abscess of the anterior vagi- 
nal wall, 88. 

Snake bites, 800. 

Society meetings during May, 800. 
Society meetings during June, 880. 

Society Reports : 

Alleghany County Medical Society, 179, 298, 656, 
736; Clinical Society of Louisville, 819,858 ; Har- 
lem Medical Association, 341 ; Medico-Chirurgical 
Society of Louisville, 977 ; New York Academy of 
Medicine, 455 ; Philadelphia County Medical Society 
21, 55, 94, 137, 377, 413, 575, 694, 772. 

Sodium hyposulphite as an intestinal disinfectant, 633, 

Sodium salicylicate in renal colic, 40. 

Solar plexus, degeneration of, in insane, 269. 

Soles, pneumatic, 318. 

Solis-Cohen, Solomon, M. D. — Physicians and patent 

medicines, 809. 
Solutol and solved, 559. 
Solved. 559. 

" Song of the Bacillus," 479. 
Song of the saddle-bags, 119. 
Spastic infantile spinal paralysis, 108. 
Specific gravity of the blood in disease, 228. 
Spina Bifida, 685. 

Spinal column, syphilitic diseases of, 68. 
Spinal eord, motor paths in, 748. 
Spinal cord, stab wounds of, 194,. 470. 
- Spinal symptoms of gonorrhoea! origin, 33. 
Spine, fractures and injuries of, 49. 
Spleen and haemoglobin, cells of, 150. 
Splenomegaly, primary, 32. 

Spondylitic paralysis, resection of spine for, 153. 
Spondylitis, 608, 645: : ; 
Sputum, examination of, 709. 

Surgical pyelitis, 161. , - ' 

Stab wounds of spinal cord, 194. ' ' i ' 

Stammering, nature and treatment of. 105. ' 

State Board of Health, National Conference, 868. 

Status epilepticus, treatment, 391, 906. 

Steele, G. M.— Fracture of the patella, 969.- ■ 

Stelwagon, Henry W., M. D. — lJrtiea:ria, psoriasis, and 

sycosis, -241. - 
Steam in sterilizing dressings, 152. 



Index. 



XV 



Sterilization, of brushes, 109 ; of medicines for hypo- 
dermic use, 269. 

Sterilizing dressings by means of steam, 152. 

Stewart, John S. — Use of gelatine discs in the eye, 686. 

Stimpson, A. 0. — Hawthorn twig in man's ear for 
twenty years, 504. 

Stockton, Prof. Chas. C, M. D. — (Edema as a symptom 
occurring in malignant diseases, 81. 

Stomach, foreign bodies in, 366 ; gun-shot wound of, 
771,- malignant disease of, 405; new method of 
measuring its capacity, 791. 

Stomatitis, gonorrhoeal, in an infant, 77. 

Strangulation, internal, 753. 

Stricture, treatment when due to incomplete rupture of 

perineal urethra, 833. 
Strontium bromide, uses of, 705. 
Strontium in Bright's disease, 42. 
Strontium salts in medicine, 704, 
Strophanthus in the treatment of goitre, 870. 
Strophulus infantum, 795. 
Strychnine, action on the stomach, 870. 
Strychnine as an antidote in opium poisoning, 986. 
Strychnine no cure for drunkenness, 192. 
Sublimate poisoning, fatal, and perforation of the 

uterus by sound, 154. 
Sugar in urine, test, 477, 598, 719. 

Sulphonal as a hypnotic, 902 : effects of, 707 ; effects 
on the circulation, 748 : in trismus nascentium, 120. 
Sulphaminol orthio-oxphenyldiamin, a disinfectant, 30. 
Surgeon and patient, 472. 

Surgeons, Military, of the National Guards of the U. S., 

Association of, 40. 
Surgery, examination of the blood in, 34 ; modern. 
Surgery, intra-cranial, in Italy, 948. 

renal, 71, 354. 
Surgical knowledge, necessity of, in general practice, 

291. 

Surgical procedure, new, 872. 
Surgical pyelitis, 161. 

Suture, buried, 394; new form of, 229, 911; in simple 

fracture of the clavicle, 313. 
Suturing of nerves, 74. 
Sycosis psoriasis and urticaria, 241. 
Syringomyelia, morbid changes in joints in, 120. 
Sympheotomy, antiseptic, 912. 

Syphilis, 820; acute iodism and its dangers in, 790; 
albuminuria in 587; cerebral, 350: inoculation of 
physicians by, 656 ; spontaneous amputation of the 
toes, 468 : tabulated treatment of, 146 ; therapeusis, 
511. 

Syphilitic affection, bromide of potassium in, 746. 
Syphilitic diseases of the spinal column, 68. 
Syphilitic hysteria, 392. 

Syphilitic infection, by instruments, alleged, 805; 

through shaving, 437. 
Syphilitics, treatment of those disposed to nervous 

'troubles, 942. 
Sweat, constitution of, 319 ; microorganisms eliminated 

by, 917. 
Syzygium in diabetes, 870. 

Tachycardia, essential paroxysmal, treatment of, 147; 

treatment, 465. 
Tait, Dudley, B. S., M. D.— Surgery of the liver, 8. 
Tamponade, intra-uterine, two cases of, 355. 
Tannin in diptheria, 480. 
Tartaric acid, synthetic, 919. 

Taylor, J. Madison, M. D. — Exercise in childhood and 

youth, 841. 
Tea as in China and Japan, 439. 
Teeth, artificial, from a hygienic point of view, 476. 
Teeth, mouth wash for carious, 6.S. 
Temperance and the longevity of clergymen, 597. 
Temperature, of drinks, 360 ; high, explanation of 

danger, 437. 
Tendons, restoration of defects in, 314. 
Tertonal in mental disease, 943. 
Testes, tuberculosis, in children, 997. 
Tetanoid convulsions in an infant, 607. 



Tetanus, cephalic, 226 ; hypodermatic injections of car- 
bolic acid in, 466; of gastric origin, 909 ; puerperal, 
554; specific for, 789 ; traumatic, treated with large 
doses of chloral, 898; traumatic, treated by carbolic 
acid injections, 987; puerperal, after abortion, 994. 

Tetany in menstruating, pregnancy and lactation, 155. 

" Texas shotgun," 478. 

Theceitis, 401. 

" The physician," 520, 958. 

" There's the rub," 280. 

Thermic fever complicated by croupous pneumonia, 48. 

Thermometric scale, new, 598. 

Thimble, poisonous, 79. 

Thilanine, 1018. 

Thiol in skin diseases, 942. 

Thio-oxvphenyldiamin or sulphaminol, a disinfectant, 
30. 

Thomas, G. D,, M. D.— Latent nephritis, 454. 
Thompson, J B,, M. D. — Traumatic tetanus treated 

with large doses of chloral, 898, 
Thompson, Dr. Lucia Redding, 119. 
Thompson's disease, 946. 

Throat and nose, pathological conditions of as casual 

factors in asthma, 166. 
Thumb, dislocation of the end bone, 852 ; treatment of 

irreducible luxations, 470. 
Thymacetin,438, 678. 

Thyme, common, in whooping-cough, 19-, 317. 
Thymolina, substitute for listerine, 272, 

listerine, 272. 
Thyroidectomy in exophthalmic goitre, 554. 
Tibia, tuberculous disease of, 684. 
Tic convulsiv, 469. 

Tissue resistance and tissue cells, 490. 
Tobacco, attempt to render harmless, 518 ; in obstet- 
rics, 272. 
Tocci brothers of Locana, Italy, 887. 
Toes, fracture of, 923. 
Tongue, pilocarpine for dryness of, 267. 
Tonsillitis, contagiousness of, 998. 

Tonsillotomy, etiology, prophylaxis and therapeutics of 

haemorrhages after, 230, 
Torticollis, acute, treatment, 788. 
Toy balloon in the trachea, 954. 
Transformation of virus, 358. 
Trauma, neuroses and neuro-psychoses after, 589. 
Tremor, hereditary, 946. 

Trephining, prehistoric, 832; the vertebral column in 
gunshot wound of the spinal canal, 231. 

Trional and tertonal in mental disease, 943. 

Trichinosis, arsenic fd.r, 120 ; benzine in, 278, 788. 

Tricocephalu?, disorders caused by, 107. 

Tubercle bacilli in the aqueous humor of cattle, 79. 

Tuberculin, immunity conferring principle in the blood 
of animals treated with, 677; composition of, 199 ; 
in laryngeal phthisis, 66 ; in treatment of leprosy, 
744; in the treatment of lupus, 29. 

Tuberculosis, and alcoholism, 918 ; and erysipelas, 7 48 ; 
dissemination in cars, 477; prophylaxis and treat- 
ment, 844; pseudo, 710; transmitted by seminal 
fluid, 808; hereditary, prophylactic treatment, 956. 

Tuberculous infection, predisposition to, 237. 

Tucker, J. P.— Perityphlitis, 936. 

Tumenol, 345, 389. 

Tumors and plastic operations treated by overheating 

the tissues, 390. 
Tumors, primary, of the heart, 226; translucency of 

solid, 835; tuberculous laryngeal, 871; abdominal, 

979; of frontal lobes, disturbance of equilibrium, 

989. 

Turnbull, Lawrence, M. D., P. H. G. — Organs of hear- 
ing and life insurance, 126. 

Turner, John B., M. D. — Treatment of membranous 
croup, 412. 

Tylophorine, a new emetic, 839. 

Typhoid fever and salads, 837; and insanity, 311; 
chlorine water and quinine in, 465 ; chloroform in, 
830; in New York, 579; peroxide of hydrogen in, 
224; treatment, 586; chlorine in, 970. 



xvi 



Index. 



Ulceration of the mouth as symptoia of lead poisoning, 
227. 

Ulcers, method for grafting, 73; extirpation of vari- 
cosities for, 313 ; old, on leg, treatment of, 271: per- 
forating, nerve stretching in, 890 ,• varicose of leg, 
treatment, 432, 

Umbilicus, septic disease of, 196. 

Uraemia, benzonaphthol in, 426 ; treatment of, 65. 

Ureemic coma and convulsions, treatment, 907. 

Urea, action of, on the vascular walls, 107 ,• new method 
of estimating, 359. 

Urethra, female, prolapse, 556. 

Urethra, male, aetiology and treatment of obstructions 

of, 734. 
Urethra, stricture of, 402. 
Urethral carbuncle, 825. 

Urethritis, abortive treatment, 472 ; bichloride of mer- 
cury in, 706. 

Urine, disappearance of sugar from, 670 ; in the insane, 
406 ; reaction with ether, 919 ; test for sugar in, 477; 
toxicity of the insane, 679. 

Urticaria, iodide of potash in, 318; jaborandi for, 
224; of throat from eating mussels, 468; psoriasis 
and sycosis, 241. 

Uterine cavity, rapid exploration of, 396. 

Uterine fibroids, electricity in, 274; treatment of, by 
combined galvinization and faradization, 240. 

Uterine haemorrhage, rapid dilatation of uterus for, 754. 

Uterus, cancer of, early diagnosis of, 197 ; effects of 
caustics on, 726, 756; extirpation of for submucous 
fibroid, 716 ; non-puerperal, inversion of, 135; preg- 
nant, prolapse, 514; puerperal inversion of, 593; 
rupture, 913; rupture in early labor, 874; total ex- 
tirpation of, 114; toial extirpation for malignant dis- 
ease, 47; rupture at the beginning of labor, 951. 

Vaccination, ancient Hindoo, 677 ; as a prophylactic 
against influenza, 198; death after, 717; efficient, 
what is, 277 ; in Austria, 92. 

Vagina, laceration of, 395 ; occlusion of, 794, 

Vaginal wall, abscess of the anterior, 88, 

Vapor, iodoform, in whooping-cough, 37. 

Varicocele and neurasthenia, 552. 

Varicola, treatment of, 72. 

Varicosities, extirpation of, for ulcers of leg, 313. 

Variola and vaccine, 758. 

Vaseline, detection of fats mixed with, 279. 

Vegetable butter, 116. 

Vehicle for bismuth, 147 . 

Version, forceps as an aid, 952. 

Vertebral column, trephining, in gunshot wound of, 

231. • 
Vertigo, Meniere's, and semicircular canals, 67. 
Vertigos, semeiology, 871. 
Vienna Medical Society, 958. 



Viennese custom, morbid, 400. 

Vinegar, method of determining the presence of free 

mineral acids, 957. 
Vin. iodinii comp. in the treatment of catarrhal aflFec- 

tions of the air passages, 21. 
Virus, transformation of, 358. 
Viscera, movable, 225. 
TisitiDg Js'urse Society, 839, 760. 

Vomiting, lavage in, following chloroform, 29 ; treated 

by blistering over vagus, 388. 
Vulvo-vaginitis, in little girls, 517. 

Walbridge, L. P. — Mechanical treatment of chronic 
rheumatism, 855. 

Ward, M. B. — Protest against the carelessness in ex- 
amination and treatment of female patients, 217. 

Water, as a local anajsthetic hypodermatically injected, 
464; as a therapeutic agent, 890; bacteriological 
examination of, 557; cure, Kneipp's, 146; drinking, 
bacteria in, 358 ; drinking, to test for impurities, 79. 

Weather, influence on disease, 39. 

Werder, X. 0. — Peritonitis, 173. 

Werner, Marie B. — Contraindications for use of opiates, 
368. 

Whooping-cough antipyrin in, 758 ; common thyme in, 
195, 317 ; early symptom of, 156 ; inhalations of 
ozone, 275 ; iodoform vapor in the treatment of, 37 ; 
naphthaliu in, 274, 595 : quinine as a remedy for, 
357 ; remedy, 638 : second attack, 517. 

Wight, J. S. — Bone in the throat, 572 ; dislocation of 
end bone of thumb, 852. ■ 

Willard, De Forrest, — Fractures and injuries of spine, 
49. 

Williams, Chas. B. — Thermic fever complicated by 

croupous pneumonia, 48. 
Williams, Roger. — Postpartum haemorrhage, 652. 
Wilson, H. A.— Clinical Lecture, 203, 608, 644. 
Wilson, 0. W.— Cephalhtematoma, 732. 
Wine drinking at dinners, 464. 
Woodhead, G. Sims, — Phagocytosis, 487. 
Woolsorter's disease, 512. 

Worshipping medicine bottles in Burmah, 159. 
Wounds, healing after bloodless operations, 713. 
Wright, Almroth E. — Phagocytosis, 535. 
Wrist, swelling of, 402, 

Wry neck, spasmodic, 672 ; new operation for, 153. 

Yeast, in enteric fever, 66; in treatment of typhoid 

fever, 147. 
Yellow fever, treatment of, by cold, 348. 

Zenner, Philip — Symptomatology of general paralysis, 
1006. 

Zona, in children, 637 ; in diabetes, 468. 



Vol. LXVI, No. 1. 
Whole No. 1818. 



JANUARY 2, 1892. 



$5.00 per Annum. 
10 Cents a Copy. 



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THE 

MEDICAL AND SUMICAL 
REPORTER 

EDWARD T. REICHERT, M. D., Editor. 

Entered as Second-Class matter at Philadelphia P. 0. P. 0. BOX 843, PHILA., PA. 



CLINICAL LECTURES. 

Prof. Ducamp, M. B., Montpelier, France. 
Hydatid Cysts of the Brain ; Alternate Paraly- 
sis (Oculo-Motor and Pathetic Paralysis of the 
Right Side ; Hemi-Anaesthesia and Hemi-Par- 
alysis of the Left Side); Hemiparesis less 
Marked oil the Right Side ; Double Optic Neu- 
ritis. . . • 

COMMUNICATIONS. 

John B. Roberts, M. D., Philadelphia. 

Clinical Contributions to Brain Surgery. . . 
J. P. Crozer Griffith, M. D., Philadelphia. 
Details About Colorado Springs in the Climatic 

Treatment of Phthisis 

Joseph B. Potsdamer, A.M., M.D., Philadelphia. 
Vin lodinii Comp. in the Treatment of Cat- 
arrhal Affections of the Air Passages. . . . 

SOCIETY REPORTS. 

Philadelphia County Medical Society. . . . 

SELECTED FORMULA 

EDITORIALS. 

The Necessity for the More General Use of 
Abdominal Palpation and Pelvimetry in Ob- 
stetrical Practice 

Obituary.— E. B. P. Kelley, M. D 



15 



21 



CORRESPONDENCE 27 

BOOK REVIEWS 28 

PERISCOPE, 
Therapeutics. 

Resorcin in Laryngeal Phthisis — Phenocoll 
Hydrochloride in Malaria — The Subcutaneous 
Injection of Atropia as a Hemostatic — Tuber- 
culin in the Treatment of Lupus — Lavage in 
Vomiting Following Chloroform — Sulphaminol, 
or Thio-Oxyphenyldiamin ; A Disinfectant — 
Treatment of Buboes — Treatment of Injuries 
to the Head — Oxygen Inhalation — Antipyrin 
in Affections of the Pharynx and Larynx — 
On the Therapeutic Value of Nerve-Stretching- 

Cresol Solutions 28> 

Medicine 31i 

Surgery • .... 34 

Gynecology 35 

Obstetrics , ... 36 

Pediatrics 37 

Hygiene 38 

Medical Chemistry 39 

CLIPPINGS AND NEWS ITEMS 40 




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THE 

MEDICAL AND SURGICAL 
REPORTER 

No. 1818. PHILADELPHIA, JANUARY 2, 1892. Vol. LXVL— No. i. 



CLmicAL Lecture. 



HYDATID CYSTS OF THE BRAIN; ALTER- 
NATE PARALYSIS (OCULO-MOTOR AND 
PATHETIC PARALYSIS OF THE RIGHT 
SIDE; HEMI-AN^STHESIAANDHEML 
PARALYSIS OF THE LEFT SIDE); 
HEMIPARESIS LESS MARKED ON 
THE RIGHT SIDE; DOUBLE 
OPTIC NEURITIS. 



BY PROF. DUCAMP, M. D., 

CHIEF OF THE MEDICAL CLINIC IN THE FACULTY OF 
MONTPELIER. 



Gentlemen: — Hydatid cysts are not fre- 
quently met with in the brain. Of 363 cases 
of tumor of the brain recorded by Davaine 
only in 20 were these cysts found ; and in 
16 out of the 136 collected by Cobbold. Of 
the 40 observatioDs made by Morgau, in 10 
cases the cysts were found in the cerebral 
lobes, in 8 in the cerebellum, in 4 in the 
ventricles, in 2 in the corpus callosum and 
in 1 in the frontal lobes\ I wish now to 
call attention not to the rarity of the disease 
but to the cerebral troubles, perfectly local- 
ized and circumscribed, produced by the 
presence of a large hydatid tumor. I shall 
discuss with you the nature of these troubles. 

History. — Alexandrine Devr, 17 years 
of age, was admitted to the St. Eloi Hos- 
pital, on the 22d of June, 1889, during the 
service of Castan, Sr. 

Her family history showed that both 
father and mother, still living, are victims of 
rheumatism, and that a sister died at the 
age of 18 months, from convulsions. In re- 
gard to her individual history we learned 
that in childhood she suffered from cervical 
adenitis, and later on from a defective men- 
struation. The present malady began three 
months ago and was then only characterized 
by headache and constipation. A month 

1 Rabot Kyste hydatiyne du cerveau. Progres 
Medical, February 23, 1890. 
1 



afterwards, the patient was obliged to go to 
bed, owing to a moderate continuous fever, ac- 
companied by vomiting, sharp, intestinal 
pain and an aggravated condition of head- 
ache and constipation. These symptoms 
rendered her unable to get up for a little 
more than a month until the young lady 
was taken on the 22d of June to the sub- 
urban hospital mentioned. The cephalalgia 
continued to increase, vomiting became 
much less frequent, but the constipation per- 
sisted. Fever was slight, never going above 
38° C. The pulse ranged from 80 to 90. 

A marked intellectual apathy was ob- 
served ; paresis of the extremities came on 
progressively, and was especially marked on 
the superior extremity of the left side. The 
dynamometric measurement gave 19 kilo- 
grammetres for the right and 10 kilogram- 
metres for the left hand. There was com- 
plete loss of sensation on the right side of 
the body, the same phenomenon being man- 
ifested on one half of the face. 

Vision was disturbed ; on both sides the 
visual acuteness was diminished V. O. D. 
G. \. Perception of colors remained intact. 
On the left side a slight falling of the eyelid 
and external strabismus due to complete 
paralysis of the internal rectus muscle were 
observed ; this latter lesion producing a 
crossed horizontal diplopia. The pupil was 
dilated but was still sensible to the action of 
light and to accommodation. This dilata- 
tion was increased by atropine. The right 
eye exhibited no external abnormal appear- 
ances. 

Ophthalmoscopic examination showed 
more marked alterations of the left eye, an 
engorged disc, and tumefaction — in fact, all 
the characteristic signs pertaining to an 
optic neuritis to the typical choked disc. 
There were also some signs of ecchymosis. 

Examination of the different organs, such 
as the lungs, the liver, the heart, etc., gave 
negative results; they were apparently 
healthy. 

On the 6th of July the dropping of the 
right eyelid became considerably increased, 



2 



Clinical 



Lecture. 



Vol. Ixvi 



ptosis being finally complete, accompanied 
by paralysis of the superior rectus muscle. 

By the 13th, complete paralysis of all the 
muscles of the right eye, with the exception 
of the external rectus, was established, but 
there was no variation in the size of the 
pupil. 

Finally, on the 15th of July the patient 
passed suddenly into a comatose state, the 
respiration became difficult, and death took 
V place in a few hours, without there being 
noticed, in all the course of the disease any 
other alteration of the temperature or 
of the pulse than that mentioned. There 
were no convulsions, no incontinence of 
urine, no albuminuria, and no glycosuria. 

Autopsy. — There was no inflammation of 
the meninges. From the moment that the 
brain was removed from the cranial cavity 
it was clearly perceived that the right hemi- 
sphere was considerably enlarged. On the 
external face of the right sphenoidal lobe, 
between the corresponding convolutions, a 
transparent pouch filled with fluid was 
found. This tumor, independent of the 
healthy white substance, of easy enucleation, 
occupied the posterior half of the sphenoidal 
lobe and extended to the anterior half 
of the occipital lobe, without affecting the 
cortical gray substance. The tumor was not 
in direct contact with the lateral ventricle 
nor with the internal capsule, nevertheless 
they exhibited signs of compression, especially 
marked at the internal face of the sphenoi- 
dal lobe and near the peduncle. Puncture 
of this sac produced in a rapid and progres- 
sive manner a diminution in the size of the 
right hemisphere, owing to the escape of a 
clear liquid resembling distilled water, the 
quantity of which reached 250 grammes. 
This liquid revealed on examination a spe- 
cific gravity of 1006, but no albumen or 
glucose. It contained however 0.74 grammes 
per 100 of chloride of sodium. The sac was 
found to be elastic, and under the micro- 
scope exhibited no external connective 
tissue, but was chiefly composed of stratified 
fibres without any cellular elements. Over 
two points were noticed small opaque or 
whitish granular matter. The rest of the 
encephalic mass was healthy. 

Remarks. — In the presence of this clin- 
ical case whose evolution was not entirely 
studied at the hospital, a diagnosis rested 
between a tubercular meningitis and a 
tumor of the brain. Although the tempera- 
ture and the pulse would exclude the idea 
of tubercular meningitis, yet, the duration of 
the malady, the cephalalgia, the vomiting, the 
constipation, the general paralytic phenom- 



ena, and the fact that a sister of the patient 
had died from convulsions at the age of 18 
months, all pointed to the probable exis- 
tence of that inflammatory affection. The 
ophthalmoscopic examination alone, how- 
ever, revealed to us an unmistakable sign 
and sustained the diagnosis of a cerebral 
tumor. We discovered, in fact, the presence 
of a choked disc, characteristic of a tumor of 
the brain. 

True it is that tubercular meningitis pro- 
duces alterations of the disc as we have had 
occasion to study before, but these dififer so 
materially in their intensity, that the error 
of diagnosis could not have been made. 
Moreover, the tumor by its mere presence in 
the brain is alone sufficient to explain the 
various phenomena observed, and especially 
the motor disturbances which, as P. Grasset 
has remarked, " show from the very begin- 
ning a progressive paralysis^" The slight 
elevation of temperature can only be attrib- 
uted to the state of congestion determined 
in the brain at the neighborhood of the 
tumor. Under such circumstances a correct 
diagnosis was extremely difficult. That of 
tubercular meningitis was suggested by the 
history of the case, by the march of the dis- 
ease, and even by the signs revealed by the 
microscope, as the lesion might possibly have 
been a cerebral tumor of a tubercular na- 
ture. But if we excluded this diagnosis to 
what other cause could be attribed the series 
of phenomena presented by the case ? A 
careful examination revealed no history of 
syphilis. Now, vascular tumors, glioma, sar- 
coma, ecchinococcus and cysticercus are an- 
tagonistic, we may so say to tubercular 
lesions, and out of these different hypotheses 
we could not formulate a correct or even 
reasonable diagnosis. 

Finally, the anatomical signs exhibited by 
the ophthalmoscope added nothing to the 
clearing of the question and taking all into 
consideration, we could not but ascribe the 
trouble to the existence of a cerebral tu- 
mor. 

The anatomical lesions however, were not 
sufficient, and in nervous pathology we must 
look for, and determine if possible, a topo- 
graphical diagnosis. The predominance of 
paralytic disturbances on the left side, and 
the anaesthesia limited to the same side, in- 
dicated in a clear manner that the tumor 
rested largely upon the right side of the 

^ Ducamp. — Des manifestations opthalmosco- 
piynes de la meningite tuberculeuse. These de 
Montpelier, 1888. 

2 Grasset. — Traite des maladies du systeme Ner- 
veux. 



January 2, 1892. Clinical 



Lecture. 



3 



encephalic mass. The co-existence of these | 
motor and sensory phenomena, with altern- 
ate oculo-motor and pathetic paralysis 
pointed to a lesion of the cerebral peduncle. 
It was evident, therefore, that the tumor ex- 
ercised pressure especially upon the external 
portion of the root of the peduncle. This 
alteration in the functional activity of the 
oculo-motor nerve, could only begin to take 
place in the deep portion of the peduncle at 
a short distance away from the anastomotic 
fibres of the oculo-motor of the opposite side, 
because the internal rectus muscle was com- 
pletely paralyzed, the pupil remaining sensi- 
tive to light and retaining the power of ac- 
commodation. The dilatation of the pupil, 
finally, showed us that the lesion must be 
located at the inferior surface of the pedun- 
cle, as has been established by Blanc\ 
Again, Duval, from his anatomical re- 
searches has determined pretty well the ex- 
istence of oculo-motor fibres at the superior 
portion of the peduncle, and therefore a 
pressure upon that part by the tumor could 
explain the progressive oculo-motor symp- 
toms exhibited by the patient. 

In regard to the paralysis of the superior 
oblique muscle, that was undoubtedly due 
to pressure exercised upon the pathetic nerve 
as it surrounds the external surface of the 
cerebral peduncle. It remains to consider 
whether these two cranial nerves, the origins 
of which are situated near each other, were 
not afiected by a nuclear paralysis, and that 
the succession of paralytic symptoms could 
not possibly be due to lesion of the anatomi- 
cal antero-posterior area, which, according 
to Henson and Volkers,'^ constitutes the 
common origin of the nerves in question. 
But as the internal rectus was totally par- 
alyzed, a nuclear paralysis could not be 
thought of, for " in nuclear paralysis of the 
third pair, the movements of the third pair 
are abolished as regards a converging action, 
but are intact when the movements are to 
follow those of the external rectus muscle of 
the opposite side. 

It became, then, possible to establish a 
diagnosis of a tumor pressing upon the right 
side of the cerebral peduncle, upon the sen- 
sory portion and upon the motor area con- 
taining the fibres of the oculo-motor nerve, 
and finally upon the pathetic nerve sur- 
rounding the peduncle. This diagnosis ex- 



^Le nerf moteur oculaire commun et ses paralysies. 
These de Paris, 1885, p. 111. 

2 Arch. d'Opht. de Grsefe, XXIV. 

3 Fere. Anatomic Medicale du Systeme Nerveaux. 



plained the symptoms ascribed to a lesion of 
the right side of the encephalic mass, but it 
did not explain those ascribed to lesion of 
the left side manifested clinically in a right 
hemiparesis. The presence of a tumor, the 
character of the hemiplegia less marked 
than that of the opposite side, would lead us 
to suppose that the left side of the peduncle 
was also taking part in the productions of 
the symptoms observed, decreasing, so to 
speak, from right to left, and that the only 
portion affected was the motor area, the sen- 
sory part and the fibres of the oculo-motor 
nerve remaining intact. 

Thus far, we are obliged to definitely 
admit the existence of a pressure exercised 
in a decreasing manner, as has been re- 
marked, by a tumor situated on the corre- 
sponding motor area of the right side of the 
brain. 

At the autopsy the diagnosis of these 
localized lesions was confirmed, but it was 
found that the tumor of the syheno-temporal 
lobe had produced its peculiar symptoms 
not by a direct but by an indirect pressure, 
and that this tumor, whose diagnosis would 
place it at the base of the brain, was so 
voluminous that it even occupied the external 
surface of the convolutions. 

Kemember that the tumor had produced 
sensory and motor symptoms in the ex- 
tremities of both sides, and it must also be 
remembered that Chouppe has demonstrated 
that the internal capsule may be injured by 
cerebral tumors without producing hemi- 
ansesthesia, and that Charcot has observed a 
hemiplegia caused directly by a voluminous 
hydatid cyst. 

The disassociation of the oculo-motor 
fibres appears perfectly clear in our case. 
The stage of the paralysis seems to show 
that the nerve fibres of the internal rectus 
muscle were completely paralyzed from the 
beginning, near the point of pressure, and 
more to the outside of that of the elevator 
muscle which was less affected. Later on, 
the right superior oblique muscle became 
paralyzed after complete paralysis of the 
elevator muscle, and lastly the nerve-fibres 
supplying other muscles lost their power. 
This succession of disturbances brings to our 
mind the divisions of Hensen and Volkers, 
in regard to the origin of the oculo-motor 
nerve. These physiologists describe, antero- 
posteriorly, as it were, the following centres : 
"the origin of the rectus internus muscle at 
the anterior limit of the aqueduct, above 
the posterior commissure ; then the cellular 
origin of the superior rectus and of the 
elevator ; following this, that of the inferior 



4 



Clinical 



Lecture. 



Vol. Ixvi 



rectus; and lastly, still further back, that of 
the inferior oblique." ^ 

The fibres which arise from these origins, 
to be distributed to the difierent muscles, 
have been examined microscopically by 
Kahler and Pick,^ and these authors have 
divided them into two groups : an external 
one which contains the fibres of the elevator, 
the rectus superior and the inferior oblique ; 
and a median group which cod tain the 
fibres of the rectus internus and of the 
rectus inferior. 

Our autopsy did not seem to explain this 
disposition of the fibres, since the order of 
the paralysis was as follows : internal rectus, 
elevator, superior rectus, inferior rectus and 
inferior oblique. All clinical observations 
could not possibly fail to corroborate the 
delicate microscopical researches referred to. 

In regard to the slow paralysis of the 
pathetic, it can only be explained by the 
greater resistance to pressure ofiered by 
a nerve already constituted by itself, and not 
dependent upon radical, disassociated fibres. 

If we had left hemiansesthesia and slight 
hemiparesia of the right side, our case would 
be clinically one of left hemi-paralysis as- 
sociated with crossed paralysis of the com- 
mon oculo-motor, and this, anatomically, 
would point to a lesion of the peduncle. 
Benedikt^, of Vienna, says of this lesion that 
it is " a syndrome characterized by a hemi- 
paresis and a crossed paralysis of the com- 
mon oculo-motor, associated with tremors of 
the paralyzed extremities." " In that case," 
as the author has remarked, "the lesion 
lies evidently in the cerebral peduncle on 
the level of the origin and exit of the 
oculo-motor nerve ;" and further states : 
" The syndrome which I am studying has a 
great importance, since it shows a localiza- 
tion sufficiently clear to explain the tremors. 
This motor disturbance is produced in our 
syndrome by a lesion lying in the peduncle 
at the origin of the common oculo-motor 
nerve. In sclerosis, where the tremors re- 
semble those of the disease under considera- 
tion, the lesion which causes it is found over 
the same region." Our case, which presents 
a change entirely peduncular, does not 
authorize us to recognize as yet such 
a localization for the tremors, although 
the case is different from that of Ben- 
edikt, especially in regard to disturban- 
ces of sensibility. Again, there is a little 

^ Blanc. Loc. cit. 

"^Arch. fur Psych, unci Mervnkr., x, et Prager 
Zeiisck. fur Heilkunde, 1881. 

'^Bulletin Medical, May 1st, 1889. 



diflference also, with regard to loss of sensi- 
bility, in a case reported recently by A. 
Manquat and Ed. Crasset,^ in which there 
was hemianalgesis, the authors locating the 
lesion at the cerebral peduncle, a little above 
the origin of the oculo-motor nerve. On the 
other hand, in this "instance the tremors 
are slight and are noticed on both sides." 
Without wishing to contradict the statement 
published by the authors, we cannot but con- 
clude that a peduncular lesion does not nec- 
essarily produce tremors. 

In regard to medical treatment, whatever 
it may be, it could not give any good results, 
unless, perhaps, an external opening of the 
cyst could have been established. Clemen- 
ceau has seen a case of this nature, where a 
cure was spontaneously eflfected. Was sur- 
gical interference indicated? No. The 
tumor was not accessible, as it seemed to 
occupy the base of the brain, near the pedun- 
cle and without any connection with the 
external surface of the hemispheres. The 
symptoms were all peduncular and pointed 
to the existence of a great intracranial pres- 
sure. 

Now that the malady ended in the death 
of the patient, we have frequently asked 
ourselves whether we could have agreed 
with Money, and allowed trephining to be 
performed. We mention this apropos of a 
communication of Webster^ about a case of 
hydatid cyst of the brain, which terminated 
in death, in which Money expressed his opin- 
ion here referred to. We do not forget the 
good results that trephining has produced 
in several instances in the hands of Penn, 
Gilbert Ballet, Gelineau, Lepine, and Lucas 
Champoniere, which have been reported to 
the Academy of Medicine^, but some of 
those cases were of a different nature ; on 
the other hand, when we conceive of a tumor 
reaching the external surface of the convo- 
lutions and apparently inbedded within 
them, then the gravity of the case becomes 
unquestionable. 

In conclusion, we know that this foreign 
body was an acephalocyst, of considerable 
volume, developed in the deep portion of the 
white substance, without known cause, and 
that its development was accomplished in the 
course of about four months. This duration 
is in accordance also with the published 
tables of Ball and Krishaber"^ where the 

^Un cus de paralysie alterne de I'oculo — moteur, 
avec aphsie Coriginie traumatique. Progres Medi- 
cal, February 8th, 1890. 

2 Pathological Society of London, Nov. 6th, 1888. 

3 February 19th, Aug, 6th and 20th, 1889. 

* Art, Cervean ( Tu7?ieurs) in Diet. Encyclop. 



January 2, 1892. Communications. 



5 



greatest number of cerebral tumors is re- 
eorded, the clinical evolution of such tumors 
ranging from one to six months. 



COMMUNICAT IONS. 



CLINICAL CONTRIBUTIONS TO BRAIN 
SURGERY.i 



BY JOHN B. ROBERTS, M. D., 

PROFESSOR OF ANATOMY AND SURGERY IN THE 
PHILADELPHIA POLYCLINIC ; PROFESSOR OF SUR- 
GERY IN THE woman's MEDICAL COLLEGE 
OF PHILADELPHIA. 



In 1885^ I took strong ground in favor of 
more active surgical interference in injuries 
and diseases of the cranium and brain. At 
that time the views advocated by me were 
looked upon as being too radical, and were 
quite vigorously opposed by many promi- 
nent surgeons of this country. Since that 
date there has been developed an unprece- 
dented activity in the operative treatment of 
cranial and intra-cranial lesions, which, even 
in my opinion, has been too extreme. It is, 
perhaps, not difficult to understand this un- 
scientific and unreasonable adoption of what 
might be called a surgical fashion. It is to 
be regretted that the enthusiasm created by 
success impells some men to interfere surgi- 
cally in nearly all cases that come into their 
hands without a judicious study of each par- 
ticular patient. That unrestrained mania 
for operating which has made abdominal 
surgery almost a by- word has, it seems to 
me, entered into the domain of cerebral sur- 
gery. It is just as much a part of scientific 
surgery to abstain from operating unneces- 
sarily, as it is to combat vigorously the un- 
reasonable conservatism of those who will 
not see the force of anatomical, surgical, and 
statistical evidence. Fortunately for the 
patients a healthy reaction is at last taking 
place, and surgeons are not now removing 
brain centres and tunnelling the brain in 
search of abscesses and tumors in quite as 
enthusiastic a manner as they were a couple 
of years ago. That such lesions should be 
promptly attacked surgically is unquestioned, 
but this should be done only after a thor- 
ough survey of the conditions and a judicial 

iRead before the Philadelphia County Medical 
Society, November 25th, 1891. 

2" The Field and Limitation of the Operative Sur- 
gery of the- Huma Brain, Annals of Surgery, July 
and August, 1885. 



estimate of the gain that will possibly arise. 
The experimental character of many opera- 
tions upon the brain in recent years has been 
almost as patent as in vivisectal operations 
done with an avowed experimental purpose. 
Death on the operating table and unsuccess- 
ful operations have at length begun to stay 
the hands of these over-enthusiastic sur- 
geons : and there is now ground for hope that 
cereb.-il surgery will, ere long, become less 
reckless. 

My personal opinions are very much what 
they were in 1885 ; indeed, the advances in 
diagnosis and the improvements in operative 
methods have made me even more sure of 
the correctness of the conclusions then ad- 
vanced. I cannot, however, bring myself 
to approve of the reckless way in which 
human life is often threatened by operations 
which hold out scarcely a ray of hope to the 
helpless patient. The rapidity of healing in 
aseptic wounds and the tolerance of the brain 
under operative attack do not justify hasty 
resort to intra-cranial surgery simply because 
the patient or his family are submissive 
under the persuasive eloquence of the would- 
be operator. 

I desire to-night to report a few cases 
which have a practical bearing on some of 
the fundamental principles of cerebral sur- 
gery, and I hope they will serve as a means 
of bringing out the views of others in this 
interesting field. 

Case I. — Trephining for cortical epilepsy 
apparently the result of traumatism ; improve- 
ment, followed by death in five weeks. — A 
child, twenty-nine months old, had sixteen 
months previously received a fall, and on 
the second day after the accident was seized 
with convulsions. Four months before he 
had been struck on the head by a falling 
clock, but no special symptoms followed this 
mishap. Since the second attack he had 
had spasmodic seizures occurring at frequent 
intervals nearly every day. He dragged 
the left leg a little, did not seem bright, and 
was still unable to talk. There was a slight 
tendency to draw up the mouth on the left 
side, and also an inclination to turn the 
head and body to the left. When his atten- 
tion was directed to bright objects he would 
apparently try to look at them, but his eyes 
usually turned to the left. His hearing 
seemed to be dull, but so far as could be de- 
termined the cutaneous sensibility was un- 
impaired. No changes were found by oph- 
thalmoscopic examination. 

Dr. Charles K. Mills, who referred the 
patient to me, placed the child under obser- 
vation in order to detect, if possible, the 



6 



Communications. 



Vol. Ixvi 



exact character of the spasms. He was 
watched carefully in several seizures. 
Usually he squealed at the beginning of the 
paroxysm and his face had a vacant look. 
The spasm began with a lifting movement 
of the entire body, as if with the muscles of 
the trunk, much like a sudden effort to rise 
from a recumbent to a sitting position. 
About the same time, as nearly as could be 
judged, the eyes and head turned to the left. 
The eyes did not keep to the left but oscil- 
lated with the jerking movements of the 
body ; the head, however, continually turned 
to the left. The left leg and arm were 
spastic in slight flexion and were lifted up 
and projected outward and forward, the 
limbs on the right side were flaccid, but 
were projected forward and upward with the 
jerking movements apparently communicated 
from the trunk and the left limbs. 

Another description of the attacks re- 
cords that the child awakened suddenly 
from sleep with a toss of the body, as if 
badly frightened, with the head and eyes 
at once turning to the left. The left arm 
was extended forward and upward stiff and 
rigid, with the thumb and little finger point- 
ing backward, the other fingers being 
slightly ftexed. Both legs were also tossed 
upward in the air, the left more projected 
than the right. His body was lifted up and 
down during the attacks. 

It was difficult to determine any signal 
symptom or serial order of movements. The 
spasm was both tonic and clonic, and cer- 
tainly most marked in the limbs and face of 
the left side. The movements of the leg 
and arm were those of projection and pro- 
traction, and were rather movements from 
the shoulder and hip than from and in the 
distal portions of the limbs. The move- 
ments of the head, trunk, face, and limbs 
were often nearly coincident, but the con- 
jugation of the head and eyes seemed cer- 
tainly to be most commonly the initial 
movement. 

The above description is taken from a 
former report of the case.^ 

Dr. Mills thought that the symptoms 
seemed to point to lesion of the area for con- 
jugate deviation of the head and eyes, and 
certain associated movements of the trunk, 
thigh and arm. It was, therefore, deter- 
mined to trephine over the posterior portions 
of the first and second frontal convolutions. 

After encircling the head with a rubber 
bandage to prevent haemorrhage from the 
scalp, I made an opening with an inch and 



1 Polyclinic, April, 1889, p. 299. 



a half trephine placed one and a quarter 
inches in front of the fissure of Rolando and 
a little to the right of the median line. Be- 
hind and below the opening so made I cut 
out another button of bone with a one and 
a quarter inch trephine. The spurs of bone 
between the two holes were cut away with 
forceps. One point of the aura was abnor- 
mal in thickness and rather more adherent 
than normal. This condition did not seem 
to be caused by a Pacchionian body. 

A flap of the dura was raised. The pia 
mater was very oedematous so that it could 
be pitted with the finger. A thin, yellowish- 
white membrane was found lying loosely 
upon the pia-arachnoid and had probably 
separated from the dura when the flap of 
that membrane was raised. This abnormal 
membrane was removed. Small electrodes 
applied to the convolutions failed to induce 
conitaction of the left arm. This electrical 
test was repeated but failed to give results, 
though no antiseptic solution had come in 
contact with the brain tissue before the elec- 
trodes were used. Incisions in the pia 
allowed the serum, which caused the oedema, 
to escape. When the convolutions were thus 
clearly exposed there was no evidence of 
change in their structure or of any subjacent 
lesion. The dural flap was then sutured in 
position, and the portions of bone, which 
had been kept in antiseptic solution at a 
temperature of 105°, were replaced. Some 
catgut threads were laid beneath the but- 
tons of bone and carried through the incis- 
ion m the scalp to give drainage. 

The child w^as under my observation for 
nineteen days, during which time there were 
only three epileptiform attacks and these 
were within two or three days after the opera- 
tion. They were all slight and would 
scarcely have been recognized as pathologi- 
cal symptoms if the previous severe attacks 
had not formed part of the clinical history. 
A large amount of cerebro-spinal fluid 
escaped for several days through the opening 
left by the catgut drain, which was removed 
a day or two after the operation, and also 
through a small hole in the line of incision 
which had not healed by first intention as 
had the rest of the wound. 

Bromide of potassium, calomel, and small 
amounts of alcoholic stimulants were given 
to the child during the after-treatment. 

When he was discharged from under my 
immediate care his general condition was 
good', temperature normal, and there had 
been no escape of cerebro-spinal fluid for 
three days. The two small openings in the 
scalp were covered with small crusts. 



January 2, 1892. Communications. 



7 



Two weeks later the child died, but the 
history of the intervening period is unknown. 
I heard only indirectly of his death. No 
post-mortem examination was made, but in- 
definite information has come to my knowl- 
edge, which leads me to believe that suppura- 
tion under the scalp occurred. 

This case is one of a class in which there 
is a great temptation to operate in hope of 
finding some removable lesion of the corti- 
cal centres. The findings are usually nega- 
tive ; and the results only temporarily satis- 
factory, even when the patient entirely 
recovers from the lesions incident to the 
operation. Unless the localizing symptoms 
and signs are more definite than in this in- 
stance, I think that in similar cases I shall 
hereafter be almost inclined to avoid opera- 
tive interference. This provisional conclu- 
sion has been reached by a consideration of 
cases in the treatment of which I have been 
concerned, or with whose results I am 
familiar. 

Case 11. — Traumatic epilepsy resulting 
from unsuspected fracture ; trephining with 
discovery of an irregular projection of hone on 
the interior of the cranium. — A man, J. H., 
aged thirty-four years, while working as a 
puddler, about eight years ago, received an 
injury on the left side of the head by being 
caught between an iron lever of a furnace 
door and a brick wall. He was not treated 
by a physician, and only lost about two days 
from his work, although the injured region 
was poulticed by him, and was the seat of a 
discharge for four or five months. No por- 
tion of bone came from the wound, and there 
were no special symptoms. 

Several years ago he had venereal sores 
upon the penis, but no suppurating inguinal 
glands or syphilitic developments. Chills 
and fever, several years ago, constituted the 
only illness from which he suffered. 

An examination of his head, after shav- 
ing, revealed several insignificant scars, and 
just above the zygoma on the left side, a half 
inch in front of the auricle, a depressed cica- 
trix sufficiently deep to hold the tip of the 
little finger. This was the scar left by the 
injury received eight or nine years ago. 
The cicatrix involved the temporal muscle, 
as was seen by the dragging of the skin over 
the scar during mastication. There was no 
evidence of depression of the skull in any 
other part of the cranium, and this depres- 
sion did not seem to involve the underlying 
bone. His intelligence was good ; but the 
patient said that he did not remember as 
well as he could a few years ago, and that at 



times his eyesight was not good. He shows 
at times a little mental deterioration. An 
ophthalmoscopic examination of the eyes 
gave negative results. 

The patient states that about two and a 
half years ago he had an epileptic fit after 
working in a hay-field on a hot day, and 
that since that time he has had marked seiz- 
ures about every six weeks, with lesser 
attacks more frequently. He has but one 
epileptic fit at a time, from which he rapidly 
recovers, and is soon able to walk about. 
After such attacks he feels weak for some 
time. For several years he has had severe 
headache, not confined to any one portion 
of the head, and just before the epileptic 
seizure he feels a jerking sensation on the 
right side of the nose. He complains that 
his general health has deteriorated, but there 
is no apparent loss of flesh. 

On the 26th of September of the present 
year (1891), I turned up a large flap of the 
scalp and found, after cutting through the 
temporal muscle, a depression in the skull 
one inch in length and three-eighths of an 
inch in width. This fracture was a surprise 
to me because of the history of the case and 
the situation of the injury over the thick 
belly of the temporal muscle. A three- 
quarter inch aseptic trephine was applied 
above and behind the depression. This cut 
through the bone with some difi&culty, be- 
cause the upper portion of the disc was much 
thicker than the lower part. Unfortunately 
my segment trephine had been forgotten, or 
this part of the operation could have been 
more expeditiously performed. Thinking I 
had cut entirely through the skull, I endeav- 
ored to pry out the disc, but removed sim- 
ply the outer table of the button ; I found 
that between it and the internal surface 
there was a portion of fibrous tissue entan- 
gled. It was probably this portion of tis- 
sue entangled in the bony cicatrix as a re- 
sult of the fracture at the time of the injury 
that enabled me to lift out so readily the 
upper surface of the bony disc. The entan- 
gled tissue was doubtless pericranium. Re- 
moval of the interior table of the disc re- 
vealed below and in front of the opening a 
teat-like elevation projecting from the lower 
surface of the skull and pressing upon the 
dura. This elevation was about one-fourth 
of an inch higher than the general surface 
of the interior table, and was the apex of an 
irregular elevation due to consolidation of a 
number of comminuted fragments of the 
inner table. The irregular lines of fracture, 
with the fragments displaced in varying de- 



8 



Communications. 



Vol. Ixvi 



grees, are shown on the button removed and 
the rest of the bone subsequently cut out 
with gnawing forceps. 

The specimen shows this condition very 
satisfactorily, though somewhat mutilated 
by the gnawing forceps with which the ad- 
jacent bone was removed after the original 
button was taken out. The depth of the 
skull wound and the thickness of the tem- 
poral muscle made it rather difficult to 
operate neatly, and my desire to get rid of 
the portion of bone pressing upon the dura, 
without prolonging the operation or increas- 
ing its severity, caused me to sacrifice the 
specimen in the interest of the patient. The 
dura was not opened, threads of catgut were 
use for drainage and a dry sublimate dress- 
ing was applied. 

The following day the wound was found 
to be healing by first intention, and the 
drainage threads were removed. Bromide 
of potassium and chloral were given for two 
nights, and then twenty grains of bromide 
of potassium three times a day were ordered 
as a continuous treatment. 

On the third day after the operation the 
patient had a sensation of twitching at the 
side of the nose similar to that wb^'ch 
formerly preceded the epileptic seizures; but 
he had no fit. The wound healed by first 
intention, the temperature never rose above 
98.6°, and on the eleventh day after the 
operation the patient was sent to his home 
in the centre of the State. He felt exceed- 
ingly well after the operation and expressed 
his satisfaction at the improvement of his 
condition. I suggested that the bromide 
treatment be continued by his physician. 
Dr. J. P. McCleery, under the idea that re- 
moval of the surgical cause of epilepsy 
should be looked upon as only a part of the 
treatment. I believe that in all such cases 
internal treatment should be combined with 
surgical procedures, and that the epileptic 
habit should be controlled by a prolonged 
course of bromides after the mechanical 
cause has been removed. 

Seven and a half weeks after operation his 
physician reported that he had suffered no 
return of his epilepsy and was about to re- 
turn to work. As far as it goes this state- 
ment is gratifying, but much more time must 
elapse before we can feel sure of a cure 
having been eflPected. The lesion is certainly 
one of those in which trephining ought to 
be eminently beneficial. Punctured fracture 
such as this should always be subjected to 
immediate trephining at the time of injury. 

The following cuts (Figs. 1 and 2) represent 
the external and internal appearances of the 



skull in a case trephined by me some years 
ago. There was a small scalp wound 
through which I could with ray finger-tip 
feel what I thought was rough bone. I 
found by incision that the roughness was due 
to an unusually irregular lambdoidai suture 
with Wormian bones ; and that the onW 
bony lesion caused by the blow received fr6^ 

Fig. 1. 




Outer surface of fractured cranium showing lamb- 
doidai suture, point where trephine was applied, and 
small indentation looking like entrance of a vein mad« 
by the blow. 

the pitcher, with which the patient was 
struck, was a small dent, looking like the 
opening for the entrance of a vein. The 
character of the vulnerating force, however, 
induced me to trephine. The removal of 
the trephine button and the insertion of a 
probe between the dura and the cranium 
discovered nothing except a small fissure on 
the inner surface of the disc. Death oc- 
curred -within a short time from alcoholic 
delirium ; and the autopsy revealed a T- 
shaped fracture of the inner table with a 
shelf-like detachment of quite an area of 
bone. If this patient had lived he would 
probably have had secondary epilepsy, as 
occurred in the case just reported. The 
urgent necessity of primary trephining in 
such punctured fractures, even when no 
symptoms are present, is fully illustrated by 
these cases. The many deaths from cerebral 
abscess and other inflammatory processes, 
following the receipt of punctured fracture 



January 2, 1892. Communications. 



9 



of the cranium, long ago justified the surgical 
conclusions that trephining in such injuries 
should not be delayed until the advent of 
symptoms of encephalic inflammation. The 
epilepsies resulting in cases which have 

Fig. 2. 




Inner surface of fractured cranium, showing cut 
made by trephine and large area of inner table driven 
inward under the small external indentation. The 
trephine has not cut entirely through the boiie where 
the inner table is driven inward. 

escaped the immediate dangers of encephal- 
itis add another argument to the wisdom of 
immediate operation in punctured fractures. 

Case III. — Secondary trephining for trau- 
matic epilepsy ; death from aseptic cerebral 
inflammation. — In June, 1891, I operated 
upon a man, J. T., aged twenty-eight, with 
the following history : 

While working in a mine he had been 
struck upon the head with a huge mass of 
coal and rendered senseless. The attending 
physiciau. Dr. James D. Harvey, found a 
fracture of the skull, and upon the day of 
the injury removed a portion of the bone. 
According to the patient's statement he 
recognized no one for fourteen days, and 
was, therefore, probably unconscious during 
that time. 

After consciousness returned his left arm 
was paralyzed, but gradually regained 
power. Eight months afterward he had an 
epileptic seizure, and has had epileptic 
paroxysms at irregular intervals ever since. 



He is aware of the approach of a convulsion 
by nausea, dizziness and disorder of vision. 
Occasionally he has time, after the premoni- 
tory symptoms, to sit down before the fit oc- 
curs. He thinks that he ordinarily falls in the 
convulsion, but he does not bite his tongue 
at such times, though he froths at the mouth 
and grinds his teeth. The attacks have 
occurred as often as one or two in a day, 
but he has gone as long as four months with- 
out a paroxysm. The ophthalmoscopic ex- 
amination reveals a normal fundus, clear 
media, and hyperopic refraction. He is un- 
able to say in what part of the body the 
muscular spasm begins. 

A large triangular depression is seen 
upon the right side of the head, the upper 
margin or base of which is one and three 
quarter inches to the right of the median 
line and almost parallel to it. The apex of 
the triangle points downward and forward 
toward the ear. The anterior margin of the 
depression is near or a little behind the 
fissure of Rolando, and the centre of the de- 
pression is over the superior parietal convo- 
lution, or in that vicinity. The deepest por- 
tion of the depression is that near the middle 
line of the skull, at which part its depth is 
fuily a half inch • the edge of the depression 
at this point is almost vertical. The interior 
and posterior borders are less abrupt. The 
angle, which I have called the apex of the 
depressed triangle, is about two inches above 
the ear, and a little behind a vertical line 
drawn upward from the ear. The margins 
of the depressed area form an equilateral 
triangle, each side of which is about one and 
one-quarter inches in length. There are a 
number of other scars on the head, one or 
two of which radiate from this depression. 
There is distinct weakness of the grasp of 
thfe left hand, but no marked difference in 
size of the hand or the arm. The patient 
complains of the left hand feeling differently 
from the right. There is no muscular con- 
tracture and no apparent change in the 
electrical reaction or in mensuration. 

On account of the epileptic attacks in this 
case I determined to operate and remove 
any apparent cause of irritation. If nothing 
abnormal was found, I intended to remove 
the cicatrical tissue in the bony gap and 
also the bony margin of the opening in the 
skull. Accordingly I made an elliptical 
flap in the scalp which disclosed a triangular 
depression in the skull corresponding with 
the indentation seen externally. This was 
filled in with fibrous tissue, which I dissected 
out of the bottom of the depression. The 
bone was so thick that the gnawing forceps 



lO 



Comimmications. 



Vol. Ixvi 



could not cut away the edges, hence, I used 
an aseptic trephine and removed a disc one 
inch in diameter from one corner. Subse- 
quently I made four small holes along the 
edge of the depression with a half-inch 
trephine and then was able to gnaw away 
the edges with gnawing forceps. The soft 
tissues were yelloAV, and pigmented in places 
with particles of carbon, evidently due to 
coal dust ground into the wound at the time 
of the accident. 

Before the operation pressure upon the 
scalp gave the sensation of a small cavity 
filled with air under the integument. It re- 
sembled the sensation experienced when a 
varicose vein is palpated. Eemoval of the 
shin over the gap in the cranium did not 
alter this tactile phenomenon. The yellow^ 
pigmented tissue, found as above mentioned, 
was not brain tissue ; and when cut through 
disclosed what looked like the interior of an 
emptied cyst, because the inner surface of 
the tissue had a smooth, glistening surface. 
No fluid escaped or had escaped by punc- 
ture. After having dissected away a con- 
siderable portion of this material, and hav- 
ing removed the edges of bone along the 
entire circumference of the bony opening I 
reached normal brain-tissue. Hsemorrhage 
from the cerebral wound and from the peri- 
osteum was profuse. It seemed 'impossible 
to stop that whicli came from the brain and 
its membranes, which were fused together in 
an almost indistinguishable mass at the bot- 
tom of the deep hole. The triangular open- 
ing in the skull measured about two inches 
along each margin. The pulse became very 
feeble, counting 165 a minute. Prolonga- 
tion of etherization and operation seemed 
unwise. 

After unsuccessful attempts to stop the 
bleeding by ordinary methods, I conclu'ded 
to grasp all the bleeding points with haemo- 
static forceps which should be left in the 
wound. This was done, and five forceps left 
in the wound with their handles protruding. 
Iodoform powder was dusted upon the sur- 
face of the exposed brain and strips of iodo- 
form gauze packed into the cavity. A few 
sutures were applied after the flap had been 
replaced ; the gauze strips and hemostatic 
forceps projected from one corner of the 
wound. A voluminous dressing of iodoform 
gauze and cotton was then applied and the 
patient put to bed. Seven and one-half 
hours after the operation the dressings were 
saturated with bloody serum, and, therefore, 
in order to avoid sepsis, I determined to 
reapply them and to remove the hemostatic 
forceps at the same time. This was done 



carefully, the gauze withdrawn, and the 
wound redressed with a dry antiseptic dress- 
ing. In drawing out the strips of gauze a 
little oozing of blood occurred, but this haem- 
orrhage I did not think of sufficient impor- 
tance to prevent my closing the whole wound 
with sutures and without drainage. 

The next morning the patient showed 
great restlessness, but was in a condition of 
hebetude. He, however, made his wishes 
known when he desired to urinate. Bromide 
and chloral were given to control the rest- 
lessness. 

On the second day respiration varied from 
25 to 40 in a minute, and the temperature 
was 101°. During the day the patient's con- 
dition was fairly good, though he was diffi- 
cult to control on account of his restlessness 
and irritation. The urine was passed un- 
consciously. A turpentine enema was given; 
bromide and chloral were continued. On 
the third day after the operation it was nec- 
essary to give the patient one-sixth of a 
grain of morphine hypodermatically, and to 
strap him in bed because of his tossing from 
side to side. During the day he became 
hoarse, and I discovered at the base of the 
right lung harsh rales, probably bronchitic. 
The temperature was now 101.6°, while his 
respiration was between 35 and 40. 

On the fourth day after the operation the 
note is made that he slept after a hypoder- 
mic of morphine, one-sixth of a grain, and is 
quieter. Respiration 40 to 45. His breath- 
ing, however, was embarrassed and harsh, 
somewhat of the Cheyne-Stoke'stype. At 7 
P.M. respiration was 50 ; temperature 102°. 
The wound had been left undisturbed since 
the evening of the operation when the hemo- 
static forceps were removed. The rise in 
temperature and the patient's restlessness 
made me fear that there had been something 
am iss i n my a n ti septi c p re c auti ons . I, there- 
fore, determined to inspect the wound. 
Upon removing the dressing, I found the 
flap bulging and detected a feeling of fluctu- 
ation when my finger was put upon it. I 
expected to find pus under the flap, although 
the wound had healed by first intention. I 
tore open the union, but no evidence of pus 
existed ; a soft aseptic clot of blood, how- 
ever, lay under the flap. I removed the 
clot and explored the cranial cavity through 
the operation wound with my finger in 
search for pus. The cerebral tissue was dis- 
integrated and soft, but no purulent collec- 
tion was found. I moved my finger in vari- 
ous directions in the puitaceous mass, and 
finally, when my little finger was buried its 
entire length, came upon a hard mass at the 



January 2, 1892. CommMnications, 



bottom. This, I presume, was one of the 
great ganglia. The tissue overlying this 
part was almost fluid. There was no odor 
of decomposition nor evidence of pus. At 
the time of this exploration the patient was 
moribund, and I felt fully justified in these 
radical measures. Unless I found pus he 
was sure to die. 

The dressings were reapplied ; hypoder- 
matic injections of strychinne were given. 
Respiration gradually failed and the patient 
died the next morning, which was the fifth 
day after the operation. 

It seems hardly possible that the fatal 
symptoms were due to pressure from such a 
small amount of haemorrhage under the flap, 
since there was much space by reason of so 
much bone having 'been cut away ; and, 
morever, the blood, if causing tension, would 
probably have readily escaped before the 
wound had united. I concluded, therefore, 
that death occurred from aseptic cerebral 
inflammation leading to disintegration and 
softening of the brain tissue. The pulmo- 
nary symptoms may have been secondary ; 
or he may have had a congestion, prelimi- 
nary to an acute pneumonia, acting as a 
prominent feature in the fatal result. Rapid 
respiration was certainly an early symp- 
tom. 

The case is to me exceedingly instructive, 
because the indications for operation were 
clear, and because death occurred notwith- 
standing what seemed to be perfect aseptic 
conditions of the wound, during its entire 
course. It is a good illustration of the fact 
that modern surgery has not rendered seri- 
ous operations entirely devoid of dangers. 
The diminution of the death-rate in opera- 
tions has been great in recent years, but cer- 
tainty of recovery is by no means as abso- 
lute as some reporters of operations would 
have us believe. 

The next case is reported because of the 
youth of the patient. 

Case IV. — Treiphining for depressed frac- 
ture of the skull in an infant seven months of , 
age ; recovery. — A mother, while carrying 
her seven months' old child along a railroad 
track, fainted or had epileptic seizure, and 
fell, dropping the child. When she regained 
consciousness the baby was whining and fret- 
ting a little, but did not seem badly hurt. 
After the mother reached home and removed 
the child's wraps she discovered a large in- 
dentation of the skull on the right side of 
the head, which she supposed was due to the 
child's head ha\^ng struck against a railroad 
tie, or upon the iron track. The baby did 
not have any symptoms of brain implication. 



When seen by me on the next morning 
the infant was perfectly comfortable, had 
slept well all night, played as usual, and had 
a good appetite. The mother believed the 
depression to be less marked than when the 
accident occurred. Examination revealed 
an irregular depression in the parietal and 
occipital region on the left side of the head. 
The lower extremity of the vertical diame- 
ter of this depression was about two centi- 
metres above and five centimetres back of 
the top of the ear. The depression extended 
upward six centimetres. The horizontal 
diameter — that is, that parallel to the sagit- 
tal suture — began at a point near the ante- 
rior portion of the posterior half of the 
parietal bone, and extended backward six 
centimetres, very nearly bisecting the verti- 
cal diameter. The depression at its deepest 
portion was fully a centimetre below the sur- 
face of the skull. 

At this time the patient's temperature w^as 
normal ; pulse 120. During the night two 
grains of sodium bromide w^ere given be- 
cause of slight restlessness. The bowels 
were opened by a soap suppository. 

On the second day after the accident I 
found the child feeling well and the depres- 
sion less marked than on the previous day, 
when I made the first examination. I felt 
unwilling, however, to let the injury go with- 
out surgical treatment and therefore deter- 
mined to make at least an exploratory in- 
cision, because the injury had been so severe 
as to make a very deep depression. The 
possibility of secondary symptoms, such as 
epilepsy or impaired intellect, seem to me to 
indicate this slight operative interference. 

An Esmarch's bandage was carried around 
the head before the incision was made to 
prevent bleeding. A horseshoe flap was 
then dissected up at the point of injury. 
The bone was markedly depressed, showing 
a condition similar to green-stick fracture. 
I thought I could cut through the cranium 
with a strong knife but found it necessary to 
use a trephine. A small trephine opening 
was made through very thin bone at the 
anterior edge of the depression and the por- 
tion pushed down upon the brain easily ele- 
vated with the end of a grooved director. A 
few bleeding arteries were twisted, and the 
edge of the scalp wound drawn together by 
catgut sutures. Boric acid powder and dry 
sublimate dressing was applied. 

The patient reacted from ether promptly 
and went quickly to sleep. Two grain doses 
of sodium bromide were given at intervals 
until ten grains had been taken. The patient 
was restless through the night, but a few 



12 



Communications. 



Vol. Ixvi 



drops of paregoric quieted. The bowels were 
kept open by injections of oil. 

The temperature the day after the opera- 
tion reached 101.8°, but soon all symptoms 
of fever disappeared, and on the seventh day 
the dressings were removed. The wound 
was found to have healed by first intention 
without suppuration. 

At the end of the sixteenth day the 
patient was sent to his home in New Jersey 
entirely recovered. 

In this case the accentuated character of 
the depression was the factor which led me 
to adopt operative procedures, although I 
know the tendency for depression of the 
skull in healthy infants to correct itself spon- 
taneously. 

About eighteen months ago I saw a child 
who had received during birth a very 
marked indentation of the skull because the 
head had become locked on the promontory 
of the sacrum during delivery. The depres- 
sion was situated on the left side of the head, 
and included portions of the frontal and 
parietal bones near the anterior fontanelle. 
It was about two and a half inches long and 
quite deep. The case was one of difficult 
labor requiring forceps at the hands of Dr. 
Anna M. Fullerton, and the child, when 
born, was in the first degree of asphyxia, re- 
quiring the warm bath and artificial respir- 
ation. The child had frequent convulsions, 
beginning twenty-four hours after birth, evi- 
dently due to implication of the brain ; yet 
I declined to operate because I thought that 
the indentation was probably not associated 
with actual fracture of the soft bone. The 
convulsions ceased within twenty-four hours, 
and although the patient was under observa- 
tion for several weeks, I never could con- 
vince myself that operative procedures were 
justifiable. The depression gradually lessened 
and when the child was last examined by me 
seemed unimportant. The medicinal treat- 
ment of the child consisted of sodium bromide 
and potassium iodide. I have sometimes felt 
in regard to this case that the subsequent 
history might perhaps show that it would 
have been better to have interfered. I have 
not been able thus far to succeed in tracing 
the subsequent history of the little patient. 

Case V. — Sjoecimen of cerebral tumor 
which could have been readily removed by 
surgical means. — The brain herewith pre- 
sented shows a tumor occupying the parietal 
region and was obtained from a subject in 
the dissecting-room of the Woman's Medical 
College of Pennsylvania. The history of 
the case, is therefore, exceedingly indefinite, 
though through the courtesy of Dr. George 



S. Robinson I have been able to obtain the 
following notes : 

The patient was a woman, aged 35 years, 
of intemperate habits, who had, so far as 
known, no injury of the head and was not 
discovered to be syphilitic. She was an in- 
mate of a public institution and was sent to 
its infirmary about a week before her death, 
complaining of pain in the head which 
seemed to be somewhat relieved by pills of 
an anti-neuralgic character. The headaches 
continued, however, notwithstanding medi- 
cation, and for about two days vomiting oc- 
curred. The patient then became comatose 
and paralysis of the right arm and leg super- 
vened. The pupils were somewhat dilated 
and did not respond to light. Respiration 
was slow and the face flushed. No convul- 
sions occurred, but there were slight twitch- 
ing of the facial muscles. The patient was 
not noticed to be blind or deaf. Death took 
place on the sixth day after admission to the 
infirmary. 

An examination of the specimen (Figs. 
3 and 4) shows a flat, circular tumor in the 
right parietal region lying between the dura 
mater and the cerebral hemisphere. The 
convolutions are pushed downward but are 
not infiltrated in the least degree. The dura 
has not been preserved, but it is quite evident 
that the growth was attached to the inner 
surface of the dura, since its upper surface 
is torn and it has no attachments to the con- 
volutions, but can be lifted out of its bed 
without disturbing their integrity. The 
tumor is almost circular when inspected 
from above, being 6 centimeters in the antero- 
posterior diameter, and 6.5 centimetres in 
the transverse diameter. It is flat from 
above downward, varying from 2 to 3 centi- 
metres in thickness. It occupies the right 
parietal region upon the superior aspect of 
the cerebrum. Its anterior margin lies in a 
line with the calloso-marginal fissure, and 
pushes forward the ascending parietal, or 
posterior central, convolution. The tumor 
extends backward to the parieto-occipital 
fissure crowding downward and backward 
the first occipital convolution. It extends 
outward and downward to the posterior end 
of the parallel fissure, or the first temporo- 
sphenoidal fissure, pressing upon the an- 
gular gyrus. The first and second parie- 
tal convolutions are flattened and lie under- 
neath the tumor in the concavity made by 
its growth and producing pressure downward. 
On the inner aspect of the hemisphere the 
tumor presses the convolution downward, 
being nearly 2 centimetres thick where it 
lay in contact with the falx. The anterior 



January 2, 1892. Communications. 



13 



edge of the tumor is about 1 centimetre fur- 
ther forward than the posterior edge of the 
corpus callosum. The gyrus fornicatus and 



moval. Its location immediately under the 
dura, its freedom from attachment to the 
cerebral convolutions and its moderate size 



Fig. 3. 




Diagram showing relations of brain tumor. R, fissure of Rolando ; 
IP, inter-parietal fissure ; P 0, parieto-occipital fissure; C M, calloso- 
marginal fissure. The tumor has been lifted out of its bed. 



the precuneus are pressed downward, but the 
cuneus does not appear to be pressed upon 
or displaced. 



would have made its removal easy. Its 
location behind the motor area is probably 
the reason that the patient's symptoms were 



Fig. 4. 



SUPJERfOR FRONTAL 

fissure: 



INFERIOR 
rRQNTAl, / 




interparietau 
fissure; 



OCCI PI TAU 
Fl SS UHC 

IT&L 

ABALLEU 



FISSURE OP 
S YUV I U S 

Diagram showing lateral view of the cerebral convolutions and fissures, to aid in making the 
description clear. 



No surgeon can look upon this specimen 
without a feeling of regret that he could not 
have had an opportunity to attempt its re- 



not marked until just before the fatal ter- 
mination of the disease. Her habits of life 
and surroundings were such that she would 



14 



Comfminications. 



Vol. Ixvi 



not be likely to call a physician's close 
attention to the early manifestations of cere- 
bral disorder, if indeed these were apparent 
to the patient herself. A large opening 
made with trephine, gouge, or saw, followed 
by a similar incision of the dura would 
have enabled the operator to lift the tumor 
from its bed without hjemorrhage or distur- 
bance of the cerebral convolutions. The 
growth is probably a fibroma. 

The occurrence of right-sided paralysis 
seems rather curious, but Dr. Robinson 
states that he is sure of the correctness of 
this note, for he remembers that she used 
her left hand during her final illness. There 
is no evidence of a second tumor on the left 
side. Possibly the growth may have so 
pressed against the falx as to have impeded 
the current in the superior longitudinal 
sinus, and thus have given rise to pressure 
on the left cortical centres near the upper 
end of the fissure of Rolando. Unfortu- 
nately, I did not see the specimen until after 
the dura and falx had been removed. 

Case VI. — Probable basal cerebral tumor, 
in ivhich operation was deemed inadvisable. 
— In September, 1889, a man, aged thirty- 
four, was referred to me by Dr. H. C. Bloom, 
who had reached the conclusion that his 
patient was probably suflering with brain 
tumor. The history was somewhat difficult 
to obtain from the patient, who had evi- 
dently some impairment of mental faculties. 
In childhood he had had otorrhoea in each 
side, and thought that his present ailments, 
of two or three years' duration, had suc- 
ceeded a renewed discharge from the left ear. 
About a year before I saw him he had fallen 
insensible ; but for a year and a half previ- 
ously he had had attacks of severe pains in 
the head, to the left of the median line. 
Some failure of vision had been observed for 
eighteen months ; occasionally he walks un- 
steadily, but there is no apparent loss of 
power in arms or legs. His family thought 
his mental traits had shown change for sev- 
eral years. He is now becoming fat, sleeps 
a good deal, and is somewhat " weakminded" 
in his conversation and facial expression. 
There was no direct history of syphilis. 
Optic atrophy was found in both eyes; 
being more marked in the left, with which 
he could only see enough to count figures. The 
vision of the left eye was lx- Examination 
showed him to have lateral hymonymous 
hemianopsia and Wernicke's pupillary reac- 
tion. The fields of vision indicated a left- 
sided lesion. No deviation of the eyes was 
determined, but he thinks he has at times 
had double vision. Both tympanic mem- 



branes were perforated. He had had no 
epileptic seizures, but, as above stated, had 
once fallen unconscious. The urine had a 
specific gravity of 1010 and contained 
neither albumin nor sugar. The grasp of 
the right hand was stronger than the left, 
accountable perhaps to his profession — that 
of a dentist. Thermometric examination 
for several days showed him to be free from 
fever. 

No anesthesia nor paresis could be deter- 
mined. Dr. B. Alexander Randall's exam- 
ination resulted in finding in the left ear an 
old cicatricial condition, with a mere trace 
of discharge. The original trouble had 
probably been present in childhood, and 
was now in abeyance; though occasional 
exacerbations had in all probability oc- 
curred. The right ear was in a state of 
chronic suppuration of the attic and adja- 
cent cavities, with some likelihood of the ex- 
istence of diseased bone. No involvement 
of receptive or central auditory apparatus 
Avas discovered by the use of tuning forks. 
The patient's symptoms were thoroughly 
studied for me by Drs. Charles K. Mills, H. 
C. Wood, Edward Jackson, B. A. Randall, 
A. W. MacCoy. 

From Dr. William Osier, who had seen 
the man some months before, I learned that 
then he had had an intense optic neuritis, 
but at that time no hemianopsia. Dr. Osier 
suspected a slowly growing neoplasm ; prob- 
ably located in an anterior location, because 
of the early alteration in habits. 

Dr. Mills was inclined to think that the 
symptoms shown when the patient came 
under my care pointed to a lesion between 
the optic chiasm and the primary optic 
centres. This he considered might be a 
tumor or abscess of the inner part of the 
temporal lobe, encroaching on the optic tract 
back of the chiasm or a similar lesion of the 
cerebellum advancing and invading the more 
anterior structures. 

Dr. Wood believed the localizing symp- 
toms pointed to a lesion encroaching upon 
the corpqra quadrigemina or optic chiasm, 
which was most probably either a localized 
meningeal inflammation with much exuda- 
tion, due to diseased bone at the base of the 
skull, or a tumor there situated. He thought 
it possible that an abscess might exist in the 
temporal or frontal lobe, but there was little 
evidence to indicate this being a probability. 

This case was one that oflered a good 
many points of surgical interest ; but after 
determining that the lesion was probably 
basal and on the left side, I declined to 
operate, because there was no evidence of 



January 2, 1892. Comimmications. 



15 



the left ear being a probable cause of intra- 
cranial suppuration. If the symptoms had 
pointed to a right-sided lesion, the condition 
of the right ear would have influenced me 
strongly toward operative measures, looking 
to the evacuation of a temporal abscess. The 
association of chronic aural suppuration with 
cerebral abscess is so well known that I 
think I should have strongly inclined to ex- 
ploratory trephining. 

I accordingly declined to operate, and 
sent the patient home. I heard from him 
frequently, but he gradually lost vision and 
mental power. I had arranged for, and ob- 
tained permission for an autopsy ; but when 
he died the past summer no word was sent 
me. Previously to death he had violent 
pain in the bead, a prolonged chill, several 
successive convulsions and coma with high 
temperature. These symptoms occurred 
suddenly and terminated fatally in four 
days. Before that time he thought his eye- 
sight, which had been almost totally lost, 
was improving. The time he survived after 
my examination, nearly two years, leads me 
to believe that our abstinence from opera- 
tion was correct; since the lesion was more 
probably a tumor than an abscess. If a 
tumor, its removal was certainly impossible. 

This case presents a picture different from 
the specimen before you, in which the tumor 
could have been lifted out so readily. I 
show a diagram of the cerebral convolutions 
which may aid in following the description 
of these two cases of cerebral tumor. 

I fully recognize that the record of these 
few cases has not been one of brilliant 
results. The death of some of the patients, 
and the short time between operation and 
this report in others, make the communica- 
tion in some respects unsatisfactory. It has 
seemed to me, however, that there are ele- 
ments of interest in the histories which will 
afford food for thought and open the way 
to discussion. It is for these reasons that I 
have been tempted to give these clinical his- 
tories which are certainly not in any way 
remarkable. — For discussion, see Society 
Reports. 



DETAILS ABOUT COLORADO SPRINGS IN 
THE CLIMATIC TREATMENT OF 
PHTHISIS. 

BY J. P. CROZER GRIFFITH, M. D., 

CLINICAL PROFESSOR OF DISEASES OF CHILDREN, UNI- 
VERSITY OF PENNSYLVANIA. 



In spite of the numerous so-called "cures" 
for phthisis which have been recommended 



during the last few years, the only established 
fact of value which stands fast is that there 
are certain localities where the disease rarely 
or never occurs, and that very many pa- 
tients, sent from elsewhere to some of these 
places, may recover entirely from it. In the 
light of this fact the choice of situations for 
our consumptive patients is a matter of the 
utmost importance, as upon it may depend 
the issue of the case. 

In a former paper^ I endeavored to lay 
stress upon the existence of a climatic idio- 
syncrasy, or, as it has also been called", " in- 
dividual adaptability" ; viz., that often for 
no apparent reason a climate which suits one 
individual may in no way suit another. Al- 
though we may sometimes base upon the 
general characteristics of a patient an 
opinion as to what sort of climate will prob- 
ably prove most suitable, we are oftener but 
little able to determine this in advance, and 
are obliged to make our decision in ac- 
cordance with the results which have been 
obtained by general experience in the largest 
number of years. 

Nearly all statistics go to show that the 
results in the climatic treatment of phthisis 
are much better at high altitudes than at 
low. The truth of this is evident in the fol- 
lowing tables, constructed from the carefully 
compiled statistics of Dr. S. E. Solly^ which 
are based upon all the published statistical 
results obtainable and suitable for the pur- 
pose of analysis. (In Tables I, II, and III.) 

It is to be noted in these tables that the 
"benefited" includes both patients who have 
improved and those actually cured. 

Comparing now the condensed results in 
a third table, we have an excellent illustra- 
tion drawn from the compaj'ison of a large 
number of cases, of the therapeutic value 
of high altitudes in phthisis as compared 
with low. 

With the knowledge of these statistics we 
may be in a position to recommend a high 
altitude to our patients, but beyond this it is 
sometimes very difficult to pass. We must be 
guided here largely by such features as con- 
venience, comfort of living, pleasurable so- 
ciety and occupation, and the like, which are 
by no means unimportant factors in deter- 
mining the amount of benefit to be obtained. 

In reading somewhat extensively the lit- 
erature of the climatic treatment of phthisis, 

1 Climatic Treatment of Phthisis. Medical and 
Surgical Reporter, Feb. 14, 1891. 

2 Denison. The Preferable Climate for Con- 
sumption. Transac. Ninth Intern. Med. Congr. 
Vol. V. 

3 Advanced sheets furnished by Dr. Solly from his 
articles in Hare's System of Therapeutics. 



i6 



CommMuications. 



Vol. Ixvi 



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January 2, 1892. Communications. 



17 



I have been impressed by the absence of 
exact information concerning these details of 
the various health resorts, at least in many 
of the books and articles consulted. 

Having but recently returned from spend- 
ing several months in Colorado Springs, and 
having endeavored by observation and inter- 
rogation to learn some of the facts regarding 
it, I am led to offer the following informal 
remarks in the hope that they may prove of 
some use to colleagues about to send patients 
to the west. 

From the point of view of climate alone 
there is probably little to choose between 
various parts of Colorado and the surround- 
ing country. It is much alike in all, and, 
except that the soil of some places is more 
clayey, and therefore not to be preferred, 
one locality can hardly be selected above 
another. As regards, however, actual com- 
fort in living, Colorado Springs presents cer- 
tain decided points of advantage. It was 
founded about twenty years ago as a health 
resort, and has remained typically such. It 
is situated on a table-land 6000 feet above 
the sea and about six miles to the east of the 
foot of Pike's Peak. It is seventy-five miles 
south of Denver and forty miles north of 
Pueblo, on the main line of the Denver and 
Eio Grande railroad. The outlying range 
of the Rocky Mountains, of which Pike's 
and certain other peaks are members, is in 
full view, while in the other direction, to the 
east, is an uninterrupted view of the plains — 
a peculiar and beautiful combination rarely 
seen. 

The houses are for the most part far apart, 
and each, even the small ones, surrounded 
by its own plot of ground. There are several 
handsome business blocks, but the town does 
not do much business in proportion to its 
population. Large numbers of trees, chiefly 
the rapidly growing and leafy cotton-wood, 
are planted along the streets, making them 
very shady in summer. Indeed, seen from the 
top of Pike's Peak, Colorado Springs looks 
like a small patch of forest. 

The trees, however, are no indication of 
dampness, for, planted as they are in a soil 
which is almost purely gravel, they w^oald 
promptly die were it not for persistent and 
watchful irrigation. The same is true of the 
really beautiful summer grass. Nothing 
but the greatest care coaxes the verdure out 
of plains which would otherwise be arid. 

Colorado Springs is provided with a sys- 
tem of rapidly moving trolley cars, which 
not only carry passengers to different parts 
of the city, but extend as well to Manitou 



and other situations in the surrounding 
country. 

There are numerous good drives, leading 
both towards the mountains and the plains. 
The celebrated Garden of the Gods is a 
drive of but four miles from the town. 

The gravelly soil, already alluded to, is so 
dry that one cannot but be struck by the 
curious disappearance of the snows in winter. 
Walking about one can kick this up and 
find only dust underneath. In fact the snow 
seems not to melt but to evaporate. Only 
when exceptionally heavy does it produce 
mud, and this lasts only for a short time — 
a day or less. 

The evaporation of the snow and the rapid 
disappearance of any mud is of course in 
great measure due to the extreme dryness of 
the air. Persons newly come to Colorado 
often complain of this, as it causes chapping 
of the lips, uncomfortable dryness in the nose 
and the like. I have in fact, noticed some 
invalids drawing in with pleasure the air of 
an occasional damp day. To the majority, 
however, the dry air is peculiarly pleasant 
and invigorating. Meteorological observa- 
tions^ showed a relative humidity for the 
vicinity of Colorado Springs for four years 
of only 45.8, as compared with 65.8 for Los 
Angelos, 69 for Jacksonville and 70.2 for 
New York. 

Sunshine in Colorado Springs is abundant. 
The number of clear days estimated for five 
years gave an average of 194, with 128 fair 
and 43 cloudy days. The average yearly 
number of cloudy days in New York, esti- 
mated for the same time equalled 109. The 
amount of rain-fall is, as a rule, very small. 
The average yearly fall estimated for ten 
years was 15.87 inches, as compared with 
42.7 inches in New York. 

As in all places of high altitude the direct 
rays of the sun are powerful. In summer 
the days are often hot, but rarely so oppres- 
sive as in regions where the air is moist. In 
winter, on the other hand, the warm sun's 
rays enable patients to sit in the open air a 
large portion of each day. 

Other characteristics of high altitude seen 
in Colorado S])riugs are the sudden and vio- 
lent winds and the rapid alterations of tem- 
perature. These are, of course, distinct dis- 
advantages, so far as comfort is concerned. 
Unfortunately an equable climate, with gen- 
tle zephyrs and the like, is only to be found 
at low altitudes, and usually in the warm 
moist regions so unsuitable for consumptives. 

^ S. E. Solly, Invalid's Day in Colorado 
Springs. Transac. Amer. Climat. Assoc. 1887. 



i8 



Commtmications. 



Vol. Ixvi 



With the wind and the gravelly soil one 
encounters at times dust storms which are ex- 
tremely disagreeable. As to their hygienic 
effect I cannot do bettter than quote the words 
of a phthisical but convalescent lady whom 
I had the pleasure of meeting. " It seems 
strange," said she, " that it should be bene- 
ficial to swallow dust by the tablespoonful, 
but it appears to do no harm." 

I should however give an erroneous impres- 
sion did I imply that violent winds and dust 
storms were an every day occurrence. 

The prevailing wind during the night and 
early morning is north or northwest, which 
commonly shifts in the afternoon to south 
or south-east. 

Any further details regarding the weather 
of Colorado Springs can perhaps best be 
treated under a brief review of the different 
seasons. During the summer months, espe- 
cially rare in July and August, thunder 
showers of short duration are exceedingly 
liable to occur in the afternoon ; the bulk 
of the annual rain-fall taking place at this 
season. The mornings, however, are almost 
always clear. The nights are never damp 
and foggy as in late summer in the east, and 
I have never been able to perceive dew. The 
heat of the summer sun is evidenced by the 
thermometer rather than by the sensations, 
owing to the rapidity of evaporation of per- 
spiration. At times, however, the days are 
as warm as in the east, but the nights are 
nearly always cool, and blankets are usually 
required on the beds. 

Probably the most charming season of the 
year is autumn. For weeks at a time it may 
be that scarcely a cloud will be seen and 
but little rainfall. Patients can spend the 
entire day in the open air, and even the 
evenings are not injurious. The same is 
true of winter. Frequently the temperature 
in the night at this season is quite low; 
and now in the daytime, one realizes the 
difference between the sunny and the shady 
side of the street. The power of the sun 
under these circumstances can only be ap- 
preciated by those who have experienced 
it. The very low temperature of the north- 
west is uncommon, and the cold is not pene- 
trating as is the damp cold of the east. 

Spring is the least pleasant time of the 
year. It must be remembered, however, that 
seasons occasionally occur in which the 
amount of rain-fall and of dampness is in 
decided excess of the average. 

In March and April there is apt to be a 
good deal of cloudiness with frequent snow, 
though, as stated already, the snow rarely 
produces mud. In comparison with an east- 



ern early spring the weather is very pleasant. 
Occasionally during the winter and spring- 
there prevails a peculiar hot west wind, 
probably coming over the mountains from 
the Pacific, and called the " chinook." 

Turning again to some further details 
concerning the town and the method of life 
of those seeking it : — 

In Colorado Springs are situated a gen- 
eral hospital under the charge of the Sisters 
of St. Francis, the State Asylum for the 
Deaf, Dumb and Blind, the new Printers' 
Home in course of construction; the Colo- 
rado College for the young of both sexes, a 
club and fine club-house and two sanitaria, 
the Bellevue and the Glockner. Both of 
these latter are benevolent and most deserv- 
ing institutions, intended primarily for those 
whose means are limited. Both have been 
recently erected. 

I have personally inspected the Bellevue. 
It is pleasantly situated on elevated ground, 
is tastefully built and furnished, and cannot 
but be a comfortable and cheerful home for its 
inmates. It is in no sense like a hospital in 
its internal arrangements. The patients are 
located in separate rooms. Those well 
enough to do so meet in a common parlor 
and dining-room. Trained nurses are in 
attendance, and the physicians to the insti- 
tution are among the most prominent of 
Colorado Springs. The rates of board are 
$8.00 a week and upwards according to 
room, but even when the institution is full 
this hardly pays expenses. Nevertheless, 
cases unable to pay anything are admitted 
free at the discretion of the managers and 
physicians. 

The Glockner sanitarium is conducted on 
the same general plan. The rates of board 
are $7.00 a week and upwards. A limited 
number of free patients are admitted. Ex- 
ternally it is a comfortable-looking, roomy 
brick building. 

Colorado Springs possesses a most pleasant 
social life. A comparatively large propor- 
tion of the population consists of people of 
means and cultivation, there in the pur- 
suit of health and engaged in no engrossing 
business. The society is cosmopolitan. The 
wants of the inhabitants are well supplied 
by shops of very good grade, which are con- 
fined chiefly to a portion of a single street. 
The markets are good. On account of the 
somewhat shifting population numerous 
houses furnished and unfurnished and of all 
sizes are always to be rented. The rates of 
rent, and indeed all expenses of living are 
higher than in most parts of the east. Fur- 
nished houses of six to eight rooms bring 



January 2, 1892. Cominunications. 



19 



from $35 to $60 per month, and larger ones 
in proportion. Unfurnished houses are of 
course less expensive, and it is the custom of 
the furniture dealers to sell their goods with 
the agreement that they will receive them 
again at about half price when the custo- 
mers break up housekeeping. 

My own observation leads me to believe 
that where whole families come to Colorado 
Springs for a protracted stay it is often both 
more comfortable and more beneficial to 
keep house even though in a very small way. 
In some parts of the town pleasant apart- 
ments of two or three rooms may be rented 
for housekeeping by those whose means do 
not warrant taking a whole house. Wages 
of domestics are high — from $20 to $30 a 
month. 

The hotels or boarding houses may 
be patronized by those not desiring to keep 
house. Of the former there are several, the 
largest possessing 200 rooms. Rates at the 
hotels are from $5 a day down, with 
some reduction for a continuous stay. For 
a winter residence at a hotel it is extremely 
desirable to obtain a room heated by an 
open grate or a stove rather than by steam, 
as the latter is less easily controlled and pro- 
vides less perfect ventilation. In fact the 
steam heating often makes the hotels un- 
bearably hot in winter. Boarding houses, are 
numerous. At the best known, table board 
costs $8 to $9 weekly, and a room averages 
$20 a month ; making a total of about 
$12 a week. In less fashionable parts of 
the town good board including room may 
be had for $8 to $9 a week or even perhaps 
for less. 

For those whose health permits of it, prob- 
ably the most convenient plan is to choose a 
room to suit and to go out to a hotel or 
boarding house for meals. For women and 
for very delicate men this is frequently not 
feasible. 

Driving a^^ ^^-id'ag are the principal oc- 
cupations of ' j^. nvalids whose strength and 
means perm . Horses are cheap. Well 
broken bronchos can be bought for from $40 
to $60 and ordinary horses for a slightly 
higher rate. Stabling costs from $17 to $20 
a month, and it is probable that even still 
better rates could be obtained. Livery 
stables are numerous and safe horses can 
easily be hired. The use of a horse and car- 
riage for a half day costs only $2, and a horse 
and saddle $1.50 for the same time. The 
rates are less if taken by the month. 

Comparatively few sufferers from pulmon- 
ary diseases are unpleasantly affected by 
the high altitude even on first arriving. 



But it is well to avoid much exercise at 
the beginning. It is a mistake to suppose 
that the more one exercises the better. At 
first simply to be out of doors, even though 
confined to a chair, is all that is to be re- 
commended. The invalid should endeavor 
to spend several hours of each good day in 
the open air. Later, as strength increases 
and as one becomes acclimated, short walks 
and drives are desirable. For those in 
whose cases no contra-indication exists, 
horseback riding will be found exhilirating 
and healthful. It increases the vital capac- 
ity most decidedly. It is often supposed 
that especial virtue attaches itself to sleeping 
in the open air in summer. I cannot but 
feel that such a course is to be adopted with 
great caution. For those unusually robust it 
may be excellent, but for many it is unsuit- 
able and merely exposes them to the risk of 
taking cold without offering any real advan- 
tage in lieu thereof 

I wish, too, to emphasize the great impor- 
tance of wearing suitable clothing. Kecent 
arrivals are very commonly attacked by 
coryza and bronchitis ; attributed often to 
the dust, but due really to the lack of a 
proper appreciation of the need of watchful- 
ness against temperature changes. In win- 
ter great coats and wraps must always be 
ready at hand. Woolen underwear should 
be worn, though this need not be thicker 
than is required in the east. For delicate 
persons with poor circulation, who tend to 
feel chilly at night, woolen night-wear will 
be found a great comfort and safe-guard, as 
the bed-rooms grow cold before morning. 
In summer women may wear wash dresses 
and thin underwear in the middle of the day, 
but should change to silk or woolen dresses 
for the evening; and men should not hesi- 
tate to assume light overcoats on the first 
evidence of chill in the air. jSTo one should 
take a horseback ride of any length on sum- 
mer afternoons without carrying a good rub- 
ber coat along. 

It might seem hardly necessary to add 
that imprudences of all kinds should be 
carefully avoided, and yet it appears to be a 
common idea with many patients that 
coming to Colorado Springs is all that is 
needed to effect a cure ; and invalids are 
often most negligent in this matter. As one 
writer on Colorado has pithily put it.^ 
" There is no country where the invalid fool 
is more surely and quickly punished for his 
neglect of good advice. " On this account 



^S. E. Solly. Invalids suited for Treatment in Col- 
' orado Springs. Transac. Amer. Climat. Assoc. 1888. 



20 



Communications. 



Vol. Ixvi 



it would be best for careless patients to be 
sent to one of the sanitaria referred to, as 
results in closed resorts are known to be 
much better than elsewhere, other things 
being equal. In fact there is hardly a ques- 
tion in my mind that all phthisical patients 
in whom the disease is in an active state are 
better treated in sanitaria. The very good 
results obtained at Gorbersdorf and Falken- 
stein in Germany are to be accounted for 
largely by the constant supervision to which 
the patients could be subjected. 

It would be well for all invalids to put 
themselves under the care of a local physi- 
cian as soon as possible, even if they do not 
need treatment. Only in this way can it be 
determined whether they are profiting by 
their stay, and how long this should con- 
tinue. 

But a few matters remain to be considered. 
First of these is the question as to what 
phthisical patients should be sent to Color- 
ado Springs. Of course those in the first 
stage of the disease offer here as everywhere 
by far the best chance of ultimate recovery. 
The earlier patients are sent the better. But 
even in the second stage, unless the disease 
is very wide-spread, permanent improvement 
may be looked for. Patients with cavities 
or with evidence of rapidly advancing dis- 
ease are rarely benefited. At the same time 
such patients inevitably die at home, and as 
some remarkable cures have been effected by 
the treatment at high altitude I cannot but 
regard it as sometimes worth while to give 
them the chance for life, provided always 
that they or their friends are made to under- 
stand that but little is to be hoped for, and 
that a certain degree of risk attends the 
trial. Certain patients with very nervous 
dispositions are unsuited for residence at 
high altitudes, the great increase in the nerv- 
ous excitability interfering with any good 
which might otherwise be obtained. Serious 
valvular heart lesions, especially when not 
well compensated, or any evidence of cardiac 
weakness and irritability renders the advis- 
ability of sending phthisical patients to hio^h 
altitudes very questionable. Cases of phthi- 
sis florida are as doomed in Colorado Springs 
as elsewhere, and no possible good can be 
anticipated in such. 

To the question in what season of the year 
patients should be sent one can only answer, 
in any. Although the spring, as stated, is 
less pleasant than other seasons, yet it is 
certainly to be preferred to the spring in the 
east. Patients may lose valuable time by 
delaying their departure for any certain 
season. I would strongly urge against it. 



How long patients should stay can only 
be determined by trial in each case. A year 
is probably the shortest time ever necessary. 
For some a life-time is required. Experi- 
ence seems to show that, once cured, pa- 
tients have as good a chance of living at low 
altitudes as though the cure had not been 
accomplished at a high elevation. I have 
been unable to find any proof of the wide- 
spread opinion that those going to Colorado 
for health can, because of this act, never 
live again in the east. Patients who have 
apparently recovered and who come east 
and again fail in health, would probably 
have perished long before had they per- 
sisted in remaining at a low elevation. 

I have not yet said anything of the sur- 
roundings of Colorado Springs, and at least 
a short notice is demanded. 

Manitou, about five miles distant, is a 
well-known place of resort, particularly in 
summer. It possesses the mineral springs 
from which Colorado Springs is named, as 
there are no springs in the latter place. It 
is pleasantly situated close to the foot of the 
range of mountains of which Pike's Peak is 
one, the houses extending up among the 
foot-hills, and the place having somewhat 
the appearance of an Alpine village. For a 
summer residence it would be most pleasant^ 
as it is a centre for tourists and is full of 
life and excitement. In winter, however, 
nearly all the hotels are closed. For those 
desiring to make a prolonged stay in the 
west; i. e. for invalids, I should consider 
Colorado Springs more agreeable. 

Upon the plains and at the foot of the 
mountains and a couple of miles or so to the 
south of Colorado Springs is Broadmoor. 
The view of the plains at this point is 
superb. But few dwelling houses are as yet 
built, though doubtless the increasing size of 
the town will make building at this place 
and elsewhere in the suburV a certainty in 
the near future. Broadmoca mts already be- 
come a favorite resort for th laiternoons and 
evenings, as it possesses a ha.cdsome casino 
with excellent cuisine. During the past 
summer music has been dispensed by a small 
orchestra of high order. Attached to the 
casino are pleasant grounds and a small 
lake. Near by is the building of the Colo- 
rado Springs Country Club, already a 
favorite institution though but recently 
organized. 

There are certain phthisical patients 
whose health does not flourish during hot 
weather. For these, and for any who find 
summer heat disagreeable, there are a num- 
ber of situations close to Colorado Springs 



January 2, 1892. Society Reports. 



21 



which will be found pleasant during July 
and August. The Ute Pass, leading from 
Manitou northward contains several such 
mountain resorts of an elevation of from 
7000 to 8000 feet. Among these may be 
mentioned Ute Park, Woodland Park, 
Green Mountain Falls, Cascade, and Manitou 
Park. At a still greater elevation is Sum- 
mit Park. All of these are easy of access 
and much frequented by invalids from 
Colorado Springs. Of course there are 
numerous other resorts in the State, some- 
what farther away, though easily reached. 
I spent two months at Manitou Park and 
found the hotel pleasant, and the situation 
and weather delightful. Through all this 
region one is practically among the pines. 
All of these places offer excellent facilities 
to those desiring to tent during summer. 

None of these mountain resorts should be 
visited before July, and the remarks already 
made about the necessity of taking care in 
every respect apply to them with especial 
force. An invalid should never visit them 
in summer without taking warm, as well as 
cool clothing. 



VIN. lODINII COMP. IN THE TREATMENT 
OF CATARRHAL AFFECTIONS OF 
THE AIR PASSAGES. 



BY JOSEPH B. POTSDAMER, A. M., M. D. 

PHILADELPHIA. 



Under the name of Vin. lodinii Comp., I 
have had a mixture prepared by my friend 
Mr. Emil Jungman, apothecary at Fourth 
and ]N'oble streets, each teaspoonful contain- 
ing phosphorus, gr. t^oI iodine, gr. |; bro- 
mine, gr. \\ with aromatics and sherry wine. 
This preparation is very palatable, neither 
of the drugs being perceptible by the sense 
of taste. The dose is from thirty drops to a 
teaspoonful three times daily. A boy of 
nine can very well bear twenty drops. 

The first series of cases in which the rem- 
edy was used, was those of chronic bron- 
chitis with acute exacerbations. In all the 
cases, without any exception, the cough dis- 
appeared rapidly. Most of these patients 
had been treated on previous occasions by 
the usual routine treatment but the differ- 
ence was so marked as to at once attract the 
attention of the sufferers. The expectora- 
tion in these cases immediately began to 
diminish in quantity and to improve in ap- 
pearance. Among these cases was a man, 
who, during the intervals of the attacks, was 



perfectly free from cough but was subject to 
attacks of dyspepsia which was brought on 
by indiscretions in diet or the use of the 
usual remedy for his disease. The use of 
the vin. iodinii comp. in this case not only 
agreed perfectly but strengthened digestion. 

In cases of hard dry cough without any 
material physical signs continuing for some 
time, the cough was arrested in short order 
by the prompt administration of the remedy. 

Cases of nasal catarrh, particularly those 
with reflex cough received marked benefit 
from the use of this combination. ' 

The last stage of acute bronchitis which 
at times is difficult to eradicate promptly, 
was quickly dissipated by the use of this 
remedy. 

Lately I have been treating cases of sub- 
acute and chronic gastritis by this means 
with apparently equal success. From obser- 
vations made thus far, I expect to have as 
good results with this class of cases as with 
those of the air passages. 

This remedy has been used quite exten- 
sively by my friends, Drs. A. H. De Young, 
Geo. Roessler and F. X. O'Neill, and their 
experience fully corroborates mine. 

1333 Franklin St., Phila., Pa. 



Society Reports. 



PHILADELPHIA COUNTY MEDICAL SO- 
CIETY. 



Meeting, November 25th, 1891. 



Dr. John B. Roberts read a paper on 
Clinical Contributions to Brain Surgery. 
(See page 5). 



DISCUSSION. 

Dr. M. Price : — I should like to ask a 
question, and that is in regard to the pro- 
priety of remo^dng a clot in a case where the 
operation has been delayed for some time, 
and where, after trephining, it is found that 
the clot has become adherent, and where the 
attempt at its removal is followed by free 
bleeding. This question presented itself in 
the case of a young man injured in an iron- 
works in Phoenixville, some two weeks ago. 
A small stove shovel was thrown at him, 
the handle striking and penetrating the 
skull. For the first day or two there were 
no symptoms of paralysis. Dr. Shoemaker 
was called to the case a week or so after the 



22 



Society 



Reports. 



Vol. Ixvi 



accident, and at once decided on operation, 
at which I assisted him. There was incom- 
plete paralysis of _ the right side, and there 
had been some slight convulsive attacks. 
The trephine opening overlapped the clot 
and the dejDressed fragment of bone. As I 
have said, the* clot was adherent, and the 
attempt at removal caused free bleeding. 
We allowed it to remain, thinking that this 
would do less harm than the violence neces- 
sary to remove it. So far, the result shows 
that we acted rightly, but what the final 
result will be I cannot say. 

Some of you may recall two murder cases 
which occurred in 1873. They were both 
cases of penetrating wounds of the skull 
through the eyeball, produced by umbrellas. 
One was a man who, after the injury, came 
to the Fifth Street Dispensary, where I ex- 
amined him. He then went to his home in 
Camden, where he died in a few days. The 
second case was that of a drunken woman, 
whom I saw four hours later. She was 
wounded by her husband in his attempt to 
ward off her blows. She was removed to the 
Pennsylvania Hospital, where she died. 

Dr. T. S. K. Morton : — I did not under- 
stand Dr. Laplace to state that any provis- 
ion for drainage was made at the time of the 
first operation. That might possibly have 
warded ofi" some of the consequences of the 
injury. 

I should like to ask those present their 
views and experiences as to the results of 
operations for epilepsy. It has been my 
fortune to see a good many cases of epilepsy 
operated upon, not only where the malady 
originated in the brain, but in other ways, 
as from phimosis, contracted tendons, neu- 
ralgic testicle, etc., and in none of these 
cases, if my memory serves me right, has 
there been a permanent cure. In one case, 
where a contracted tendo Achillis was 
divided, the seizures remained absent for 
two years and then returned. It has seemed 
to me that possibly the profound ansesthesia 
has something to do with preventing the 
occurrence of the attacks. 

I had one case which was considered 
traumatic epilepsy, referred to me by Dr. 
Mills, of a child two years of age, who 
had fallen, striking its head on a piece of 
iron. Before the accident there had been 
no epileptic seizures ; after the injury seizures 
soon began, and recurred with great fre- 
quency. A thousand convulsions were 
counted in a short time. These involved 
one side of the , body, apparently beginning 
in the centres for the thumb, finger, and 



arm ; extending down the right side ; and 
subsequently becoming general. It was de- 
cided to apply a large trephine over the 
arm centre and see what was there. An 
inch and a half button was taken out. The 
dura was thickened, and I dissected it en- 
tirely away, leaving a margin of an eighth 
of an inch all around the trephine opening, 
so that haemorrhage could be readily con- 
trolled. There being no apparent lesion of 
the brain, the oedematous pia mater was 
not opened. The button of bone was not 
replaced. The flaps were sutured, and cat- 
gut drain introduced. The drain was re- 
moved ten hours after the operation, when 
the dressings w^ere found saturated with 
serum. The wound healed by primary 
union, and the child went home into the 
country on the tenth day. I understand 
that there has been no material improve- 
ment in his condition. 

Dr. Charles K. Mills: — I can recall 
ten or twelve of my own cases of epilepsy in 
which I have had operations performed, and 
I have been present at fifteen or twenty 
other operations, so that I have a personal 
experience of some twenty-five or thirty 
cases of operation for epilepsy. I have also 
paid a good deal of attention to the theoreti- 
cal part of the subject. I am sorry to say 
that the results in the majority of cases have 
not been permanently good, but I do not 
feel altogether discouraged in regard to 
cranial and cerebral operations for cases of 
this character. There are reasons why these 
operations have not succeeded. Some are 
inherent to the condition, while others are 
dependent upon errors of diagnosis, while 
still others are dependent upon the fact that 
the convulsive habit has been induced by 
the long continuance of the condition. 

I have had two cases of cortical excision. 
One of these will be reported by Dr. Keen 
in the coming number of the American 
Journal of the Medical Sciences. In this case 
a small tumor was found in the centre of 
the trephine opening, which proved to be a 
sarcoma.' A part of the cortex an inch in 
diameter was also removed. Although the 
patient improved after the operation, she is 
now practically no better than before the 
operation. It seems to me that in this case 
the brain and nervous system had been so 
influenced by the long-continued convulsions 
that they could not recover. The great dif- 
ficulty in many of these cases is the late 
period at which the operation is performed. 
In nearly all cases of epilepsy, except those 
due to recent traumatism, the afiection has 



January 2, 1892. 



Society Reports. 



23 



existed for some time. And then there are 
secondary changes which cannot be removed 
by trephining. 

I think that of all cases certain classes of 
haemorrhage present the greatest likelihood 
of benefit from operation. These are certain 
supra-dural and sub-dural haemorrhages 
which can be pretty well localized. In the 
case of Dr. Price, I think that it would have 
been better to remove the clot as a whole, 
not perhaps by traction, but by a second 
trephine opening. In some cases these dural 
and sub-dural haemorrhages do lead to per- 
manent epilepsy, even though at first no 
symptoms are present. 

I believe that the most brilliant results, 
although we have not had them yet, will be 
in cases of brain tumor. In this class of 
cases, fibromata offer more chance than other 
forms of growths, for usually they do not 
permeate the brain. Some old syphilitic 
tumors, and a few of other varieties, can be 
removed. The difficulty in these tumor 
cases is that they have been left too long. 

Dr. James Hendrie Lloyd: — The 
cause of the paralysis of the arm on the 
same side as the tumor in this case seems 
obscure, but I inferred from what Dr. 
Roberts said, he was not himself certain of 
the accuracy of this observation. I can 
hardly see how that tumor could cause hemi- 
plegia of the same side unless it acted as a 
cerebellar tumor sometimes acts — by down- 
ward pressure. In some tumors of the cere- 
bellum there is hemiplegia on the same side 
from pressure downward on the metor tracts 
below their decussation. In this case the 
tentorium would probably prevent such 
downward pressure, and I hardly see how 
the alleged fact could be explained in this 
way. The brain has not been thoroughly 
dissected, and there may be some other 
lesion, as haemorrhage or a secondary 
growth, which has caused this symptom. 

Dr. Roberts : — I was much interested in 
Dr. Laplace's case, but I do not quite under- 
stand the condition of affairs. I understand 
that the temperature which had been high, 
had descended to about normal before the 
operation. I should like to know what was 
the character of the clot some two weeks 
after the accident. Was it broken down or 
partially organized? It seems to me that it 
would be difficult to get away an old clot of 
blood which would be ubrinous from such 
an irregular surface as the base of the skull. 
I could not help thinking that possibly the 
clot removed was one due to the manipula- 
tions at the base of the brain. Again, was 
the discharge from the wound serum from 



blood-clot, or was it cerebro-spinal fluid 
mixed with a certain amount of inflamma- 
tory exudate? While the result has been 
exceedingly brilliant, I could not help think- 
ing that perhaps if no operation had been 
done the patient might still have recovered. 
As the history, as I remember it, seemed to 
indicate beginning improvement, was it ab- 
solutely necessary to keep the w^ound open 
for a number of days? I can understand 
that drainage is necessary in recent brain 
injuries, but in this case the drain was used 
at a late period and kept up for some time. 
The case is one of extraordinary interest, and 
I simply wish to have these points brought 
out clearly, as I failed to grasp the points 
when the report was read. No unjust criti- 
cism is intended, but I wish to study the 
case. 

It seemed curious that in my specimen of 
brain tumor there should be right- sided 
hemiplegia, but I think that there is a little 
question that it was on the right side. I in- 
quired in regard to the eyesight, and as far 
as known there was no blindness or deaf- 
ness. Very few symptoms were noted, as 
the patient was in a public institution and 
made no complaint until a few days befor^ 
her death. I would have been interested to 
hear in regard to the probability of the par- 
alysis being due to pressure upon the longi- 
tudinal sinus damming back the blood and 
making secondary pressure, as it were, on 
the opposite side. 

Dr. Laplace:— I would state in reply 
to Dr. Morton's question, that at the first 
dressing I put in an iodoform drain, which 
remained in until the time of the operation. 
In regard to the points suggested by Dr. 
Roberts, I would say that I was well aware 
that on the thirteenth day the clot would not 
be in the condition that it was on the second 
day. I knew that it w^ould be fibrinous, 
and in order to entangle it I devised the lit- 
tle instrument shown. 

A few hours after the accident the tem- 
perature rose to 104°, and then for the next 
ten or twelve days varied between 100° and 
103°. The coma then began to increase. 
Because the temperature before the opera- 
tion was low, it did not follow that the pa- 
tient was getting well. The patient w^as 
really worse. He was more comatose and 
he could not swallow. He had to be nour- 
ished by the bowel. Something had to be 
done, or he would die. I relieved the intra- 
cranial tension and provided for drainage. 
There must be drainage in cerebral surgery 
on account of the unyielding nature of the 
cranial wall. 



24 



Selected Formulce, 



Vol. Ixvi 



Selected Formul-^. 



FOR LUMBO-ABDOMINAL NEURALGIA. 

The following ointment is highly recom- 
mended for this affection : 

T) Salicylic acid grammes x. 

jpkJ Pulverized camphor " vj. 

Vaselin " xlv. 

M. Sig. To be rubbed frequently. 

— II. RacGoglitore Medico, November 20, 
1891. 



MIXTURE FOR SCIATICA. 

The following mixture has been employed 
with success in the treatment of sciatica: 



Fluid extract of belladonna. ..grammes 1.81. 

" " " aconite " 5.60. 

" " " gelsemium... " 22.00. 
M. Sig. 6 to 8 drops every four hours for adults. 



— II. Raccoglitore Medico, November 20, 
1891. 



IN OBSTINATE VOMITING. 

In the obstinate vomiting of certain dys- 
pepsias, H. Guimbail recommends washing 
of the stomach with either of the following 
solutions : 

t 1. 

T>, Bicarbonate of sodium grammes iv. 

Water " M. 

2. 

T> Naphthol grammes 0.25. 

±)0 Water " M. 

— Journal de Medecine de Paris, Novem- 
ber 22, 1891. 



FOR CHAPPED NIPPLES. 

In the treatment of chapped nipples 
Vinay has employed successfully the follow- 
ing formula : 



Aristol. 
Liquid vaselin. 



.grammes iv. 

" XX. 



M. Sig. To be locally applied. 

— Le Bulletin Medical, November 25, 
1891. 



INHALATION FOR WHOOPING-COUGH. 

Beall recommends, as inhalation for the 
treatment of whooping-cough, the following 
mixture : 

TX Thymol grammes 1.20. 

jL>S Phenic acid " 15.00. 

Essence of sassafras. 

Essence of eucalyptus. 

Essence of turpentine. 

Liquid tar, aa ; " 7.50. 

Ether " 4.00! 

Alcohol, q. s. for " 90.00. 
M. Sig. About 30 drops of this mixture are placed on 
a handkerchiet, and the child made to inhale it. This appli- 
cation is to be repeated every two or three hours. 

— La Medecine Moderne, November 20 
1891. 



NASAL DOUCHES. 

In the ulcerated condition of the mucous 
membrane, occurring in the tertiary form of 
syphilis, the following formula is highly 
recommended by Ricardo Botey, to be ap- 
plied in the form of douches : 

T), Pure chloride of sodium grammes cxx. 

-t>y Crystallized phenic acid " vj. 

Thymol gramme j. 

M., and make twelve powders. Sig. A powder to be 
placed in two large glasses of luke-warm water, and the solu- 
tion applied as indicated. 

— Archives Internacionales de Laringolo- 
gia, Otologia y Rinologia, December, 1891. 



FOR CHRONIC PHARYNGITIS. 

In this affection the following can be ad- 
vantageously used : 

T> Ergotine gr. xv. 

XV) Tincture of iodine 5j. 

Glj'cerin g j. 

M. Sig. To be applied three times a^day by means 
of a brush. 

— L' Union Medicaid dii Canada, Decem- 
ber, 1891. 



FOR ASTHMA. 

The following mixture, to be inhaled dur- 
ing an asthmatic attack, is of value : 

T>, Ether gj. 

JL^ Essence of turpentine o iv. 

Benzoic acid 5 iv. 

Balsam of tolu 5 ij. 

M. Sig. Applied as indicated. 

— L' Union Medicale du Canada, Decem- 
ber, 1891. 



FOR CHRONIC GOUT. 

For the local treatment of this rebellious 
malady, the following formula is recom- 
mended as being of great utility : 

T> Etheral tinct. of capsicum. 

Spirits of ammonia. 
Essence of turpentine. 

Linseed oil, aa % j. 

M. Sig. To be applied by rubbing. 

It is also said to be of value in articular 
and chronic muscular rheumatism, and even 
in chronic bronchitis. 



GASTRO-INTESTINAL ATONY. 

Dr. Germain See (J/ Baccoglitore Medico, 
No. 14, 1891), in gastro-intestinal atony 
with tympanites, uses the following : 

Magnesiae ustse | 



Cretae preparat. J aa grammes xv. ^ ^ > • 

Colombo pulocrizat grammej. ^^'^ 

Pulv. vanillse " ©.6. 

A half teaspoonful before each meal. 

Nux vomica tincture may be given in 
some cases instead of the above, with a 
saline purgative. 



January 2, 1892. 



Editorial. 



25 



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Leading Article. 



THE NECESSITY FOR THE MORE GEN- 
ERAL USE OF ABDOMINAL PALPA- 
TION AND PELVIMETRY IN OB- 
STETRICAL PRACTICE. 

The conduct of labor in [this country is 
empirical rather than scientific. This fact 
does not reflect so much upon the practi- 
tioners as upon the teachers of obstetrics. It 
has been a popular opinion that American 
women are so well formed, so vigorous, and 
healthy that labor with us is physiological, 
purely, and that much knowledge and cer- 
tain rules of practice which are of value to 
the European practitioners are superfluous 
in our more favored J.^country. This old, 
popular, soothing theory has been the cause 
of much lack of knowledge and careless 
rules of practice in this country, and indi- 
rectly has caused many deaths and has 
heaped dishonor upon our profession. 

The fact is we^have no such j inhabitants 
as this theory assumes. Especially in our 
large centres people of foreign birth, or the 
children of foreigners abound ; and our own 
women are far from physical perfection. 
Pelvic deformities are common, and are by 
no means confined to the foreign population. 

Under the old rule of practice the prac- 
titioner made no special study of an indi- 
vidual pregnancy. He assumed, as he was 
taught, that all would terminate happily, 
"because labor is a physiological process." 
No reflections concerning the relation of the 
passenger to the passage disturbed his mind; 
when called to the labor, still no special 
study of the case was made. Even an ar- 
rest of the head at the superior strait did 
not give rise to questions other than dyna- 
mic. Tedious labor he ascribed only to 
rigidity of the soft parts, or to an unfavor- 
able presentation, or to inertia. Labor not 
progressing, forceps were applied and trac- 
tion made, often great and sustained trac- 
tion. This failing, perhaps a friend was 
called who repeated the process with a like 
result. Not until this time was it considered 
necessary to study the pelvis, and but too 
I often the practitioner was ignorant of the 



26 



Editorial. 



Vol. Ixvi 



methods of mensuration to be employed. 
The results of this method of practice in 
cases of pelvic deformity are but too well 
known to us. Perhaps a dead or spoiled 
baby was delivered after the greatest effort, 
the process inflicting bruises and lacerations 
on the exhausted mother. Or at the last, 
delivery was effected by embryotomy. Cse- 
sarean section was rendered too dangerous 
to be employed except under absolute indi- 
cations, the mother being exhausted as a 
rule before this was considered. And only 
too often septic infection and death of the 
mother as well as the child closed the 
scene. 

Fortunately for our women and for the 
good name of American medicine a new era 
has dawned. Students at the present time 
are taught the anatomy of the deformed as 
well as of the normal pelvis, and the mech- 
anism of labor peculiar to the several varie- 
ties of deformity of the pelvis. Abdominal 
palpation and pelvimetry also are taught, 
and the rule of practice laid down is, that all 
primiparse should be carefully studied at least 
six weeks before term, so that any abnormality 
in the pelvis, or in the presentation of the 
foetus may be known. And the same is true 
of multiparse who have had difficult labor. 

This rule of practice places the medical 
attendant on an entirely different footing. 
Each case of pregnancy and labor is one for 
scientific study. If but slight deformity is 
found, nature can be trusted to overcome the 
difficulty with perhaps minor assistance ; if 
the deformity be considerable, labor can be 
induced at the thirty-fourth to the thirty- 
sixth week ; or if the deformity be great, 
Csesarean section can be determined upon 
and done at term as a formal operation with 
all the care usual to abdominal sections. On 
the other hand, if the pelvis is normal, as is 
the rule, practitioner and patient are reas- 
sured, since the only difficulties likely to be 
encountered are dynamic. 

K only all practitioners would follow this 
beneficent rule American practice and results 
in the management of cases of labor in 
deformed pelves would cease to be a reproach. 
Especially could the percentage of cranio- 



tomies be decreased by timely resort to the 
induction of labor, or to the Csesarean sec- 
tion, in proper cases, before the patient's 
chances for recovery are jeopardized by 
attempts at delivery by forceps or version. 

The outlay of time in examining a patient 
by abdominal palpation and external pel- 
vimetry is inconsiderable, and this is suffi- 
cient to separate the normal from the abnor- 
mal cases. Thus it is seldom necessary to 
make a vaginal examination. The benefit 
derived by the practitioner himself, more 
especially from the palpation, is inestimable. 
There is no better way of cultivating the 
iattiis eruditns, so valuable to us all. Expe- 
rience makes the results of external palpa- 
tion quite exact, so that in the diagnosis of 
the preventation and position of the foetus 
it becomes more valuable than the internal 
examination. 

In time, undoubtedly, this practice will 
become general, but that day will be has- 
tened, women in travail more surely relieved, 
and the good name of our profession con- 
served if every one who has followed the 
old system will familiarize himself with the 
principles of obstetrical abdominal palpa- 
tion and pelvimetry, and apply them in his 
daily work. 



Obituary. 



E. B. p. KELLEY, M. D. 

Dr. Edw. Bentley Perley Kelley was born 
at Campbellstown, Lebanon Co., Pa., 52 years 
ago. His early education was received at 
Strausburg Academy, and his medical 
diploma from Jefferson Medical College, at 
Philadelphia. After his graduation he was 
for a time 'connected with one of the Hos- 
pitals in the city of Philadelphia. Imme- 
diately upon the breaking out of the civil 
war he entered the Union Army as a sur- 
geon, and was soon promoted to the rank of 
Brev. Lieut. Colonel, U. S. Volunteers ; and 
later Colonel, and was Surgeon-in-chief, 1st 
Div., 1st corps, Medical Division, 6th Army 
Corps. 

He was present at 52 battles and at the 
surrender of Gen. Lee, and was finally dis- 
charged in August, 1865. What a splendid 



January 2, 1892. Correspondence. 



27 



record of service to his country ; do greater 
encomium could be needed. After leaving 
the army, he came to Perreniville, N. J. 
and entered into partnership with the late 
Dr. T. J. Thomason, and here he remained 
about 9 years. On the 15th October, 1873 
he married Miss Frances Bulkley, of Cran- 
bury, N. J., and July 24, 1874, settled at 
Perth Amboy, N. J., where he soon built up a 
large and lucrative practice. He died at his 
home, November 25, of cerebral haemorrhage, 
after only a few hours illness, and never re- 
gained consciousness from the beginning of 
the attack. 

Dr. Kelley was an excellent surgeon and a 
very skilful physician — two qualifications 
very rarely combined. 

He was a kind husband and an indulgent 
father ; a man of fine presence and a high- 
toned honorable gentleman. 

He was the trusted advisor of hundreds 
of families, and by his many acts of genuine 
charity endeared himself to an unusually 
large circle of true friends. 

He was a rigid observer of true medical 
ethics, and although he considered his first 
duty was toward his patient, no physician 
ever disliked to meet him in consultation. 

He Avas a member of the Grand Army of 
the Republic, and was never absent from a 
reunion of the Army of the Potomac from 
the time of its organization. 

He leaves a widows one daughter and a 
brother to mourn his loss. 

He was laid to rest in the cemetery of the 
Second Presbyterian church, at Cranbury, 
K J., on Saturday, November 28th, 1891. 

A delegation of Odd Fellows, Knights of 
Pythias and his G. A. R, Post were present. 

J. C. Holmes, M. D. 



CORRESPOlSrDENCE. 



DR. MASSEY'S CASE REPORTED AT THE 
MEETING OF THE PHILADELPHIA 
COUNTY MEDICAL SOCIETY, DE- 
CEMBER 12TH. 

Editor Medical and Surgical Re- 
porter: — I was unfortunately not present 
at the las meeting of the Philadelphia 
County Medical Society, the proceedings of 
which appeared in the Reporter of De- 
cember 12th, but beg your permission to 
comment briefly on the final paragraph of 
Dr. Price's remarks in closing the discussion 
on his paper, as they appear on page 940. 



It is not always possible to intelligently 
respond to the discussion on a paper that 
has taken a wide range, yet I know of few 
instances Avhere the responder was so wide 
of the mark as when Dr. Price responded to 
Dr. Woodbury. The case referred to by 
Dr. Woodbury was treated by me by the 
intra-uterine or Apostoli method after a 
non-electrical exploratory puncture, and this 
was distinctly stated by him. In view of 
the brilliant result gained from this harm- 
less treatment it is incomprehensible how the 
case can be regarded as a " proof of the 
value of operative treatment", or why we 
should be congratulated on not having a 
death instead of benefit, unless, as was 
doubtless true, the tenor of Dr. Woodbury's 
statement has been misunderstood. The 
evidence of Dr. Woodbury's case was 
strongly in favor of the electrical treatment 
of fibroid tumors, and as the reader^s of 
the Reporter can see the proof, in the 
shape of a well woman, any day, I should 
hate to have them think otherwise about it. 
Yours truly, 

G. Bettox MA8SEY. 



THE TYPEWRITER MATTER. 

To THE Editor of the Medical and 
Surgical Reporter : — Having a consider- 
able acquaintance with typewriters, and 
having done all my own work on the instru- 
ment for the last three years, I am inclined 
to think that Dr. Sherman is wrong about 
the machine being the cause of injury to the 
eyes, although I fully agree with him that 
stenographic writing is bad for weak visual 
organs. Several articles written by myself 
as to the value of the instrument in such 
maladies as writer's cramp, incipient paral- 
ysis, etc., were based on the ideas had from 
those who suflfered from such troubles, and 
who were able to do their work with the 
machine, but not with the pen, and I might 
extend these remarks by show^ing, (if space 
permitted), that in precisely such disorders 
as eye-strain, the typewriter is a most valua- 
ble adjunct in securing a cure. 

Now, it is not at all necessary to look at 
the keys when writing, and experts do not 
do so as a rule ; the action of the fingers is 
almost automatic, as it is in playing the 
piano or organ. I seldom look at the keys 
of an organ when playing, the music taking 
the attention so far as seeing is concerned, in 
case the piece is played from notes. To try 
this fully, although I usually do not look at 
the keys of my machine except casually, I 
have written this without looking at them at 



28 



Periscope. 



Vol. Ixvi 



all, hence one or two slight errors may exist. 
Although not feeling in good shape for 
writing anything, I have done this at the 
best speed possible, as a matter of experi- 
ment, and not being an expert, it will be 
seen that the work can be done so as to save 
the eyes by one who cares to learn a little, 
instead of injuring them. In speaking of 
the apparatus I refer, of course, to reputable 
machines, not the small playthings which 
require constant inspection whilst writing 
with them, (or trying to do so.) Anyone 
who uses a " Remington will find his eyes 
protected equally with his finger muscles, 
to say nothing of the time saved to himself 
in writing, and to his reader in deciphering 
what he wants to say. 

The above contains about three hundred 
and fifty words, and was written in eighteen 
minutes, allowing a few seconds to run the 
ribbon back. The fact that one occasionally 
looks at what has been written does not 
militate against the machine, for we must 
do so when the pen is used, or the pencil; 
moreover, w^e actually follow the pen with 
the eye all the time we are writing. Maybe 
the doctor can find something wrong about 
the stomach or the eyes not due to the hard 
work he does with his typewriter. 

W. R. D. Blackwood, M. D., 

Philadelphia. 



Book Reviews. 



SANDERS' QUESTION COMPENDS, NO. 21. 
ESSENTIALS OF NERVOUS DISEASES AND 
INSANITY: THEIR SYMPTOMS AND 
TREATMENT. A MANUAL FOR STU- 
DENTS AND PRACTITIONERS. By John 
C. Shaw. M. D., Clinical Professor of Diseases of 
the Mind and Nervous System, Long Island Col- 
lege Hospital Medical School; Consultating Neurol- 
ogist to the St. Catherine's Hospital, and Long 
Island College Hospital; formerly Medical Supt. 
of the Kings County Insane Asylum. 

This brief synopsis of nervous and mental 
diseases contains much to commend it to 
the student and busy practitioner of medi- 
cine. Its arrangement is simple and consis- 
tent with the modern views of the pathology 
of the afiections treated of, as far as possible. 
The author has wisely recognized the true 
scope of his work, and has not marred its 
real value as a synopsis by departing too far 
from the general outline of his subject. 
Each disease is regularly dealt with re- 
garding definitions, etiology, symptoms, diag- 
nosis, prognosis, and treatment. The forty- 
eight original illustrations, selected chiefly 



from the author's private practice, are well 
executed and add value to the work. 

The portion devoted to Insanity is of par- 
ticular interest to the student. Since it 
presents in a few words much valuable infor- 
mation regarding what is to most students a 
very obscure subject. 

Necessarily only parts of some subjects 
could be presented, and indeed one is rather 
amazed to find nearly all the diseases of the 
nervous system and mind treated in one 
little book of 190 pages. 

One feature seems misleading and in- 
appropriate in a book of this kind. We 
refer to the incomplete bibliography which 
is attached to the description of vari- 
ous nervous diseases. The bibliography of 
hereditary chorea is an instance of this, and 
this feature of the book is a literary blunder. 
With this exception we heartily recommend 
this little volume to the student and the 
profession generally as a concise, readable 
and faithful synopsis of diseases of the mind 
and nervous system. 



PERISCOPE. 



THERAPEUTICS. 



RESORCIN IN LARYNGEAL PHTHISIS. 

Dr. Tymowsky publishes in the Monat- 
schriftfur Ohrenheilkunde a contribution to 
the treatment of laryngeal phthisis. He 
considers that when the hygienic surround- 
ings of the patients are favorable, rest and 
liquid nourishment are sufficient to allow 
simple erosions and even superficial ulcers 
to heal. When the latter are of greater 
depth, and the surrounding tissue is infil- 
trated, cocaine and alkaline inhalations 
must be administered ; and when the inflam- 
mation has been reached by this treatment, 
lactic acid in a solution of the strength of 
from 50 to 80 per cent., or an 80 per cent, 
solution of resorcin, may be applied success- 
fully. Iodoform, to be useful, must be ap- 
plied twice a day, and only when the ulcers 
are covered with abundant granulations. 
Dr. Tymowsky calls resorcin the most con- 
venient of all these remedies, because it 
gives no pain, and need only be applied 
once a day. The solution must, however, 
be of the strength of 100 per cent, for un- 
healthy-looking ulcers which are undoubt- 
edly of tuberculous character, when its 
efiect may be depended on. At the same 
time inhalations of from 2 to 5 per cent. 



January 2, 1802. 



Periscope. 



29 



solution of resorcin may be substituted for 
those of cocaine. Resorcin consequently is 
antipyretic, antiseptic, and heemostatic, and 
may be given internally in quantities 
of three or four grammes a day. It is also 
used externally in various forms. Dr. Unna 
has administered it for a long time past in 
chronic recurrent ulcerations of the skin. 



PHENOCOLL HYDROCHLORIDE IN MA- 
LARIA. 

Prof. Albertoni, of Bologna, makes a very 
important communication, relating to the 
use of phenocoll hydrochloride in malaria. 
Prof. Albertoni states that he has carefully 
and extensively employed the remedy in his 
practice, and that the most excellent results 
(" I risultati sono bellissimi ") were effected 
in a number of severe malarial cases. A 
comprehensive and highly eulogistic report 
has been prepared and will be published in 
an early issue of the " Academia Medica." 
This is highly valuable information ; qui- 
nine has heretofore been almost the only 
available remedy for malaria, and even this 
occasionally disappoints. Phenocoll is 
already favorably known as a superior anti- 
pyretic and is also employed with success in 
the treatment of rheumatism. 



THE SUBCUTANEOUS INJECTION OF 
ATROPIA AS A HEMOSTATIC. 

M. Bierwirth (^Journal de Medecine de 
Paris, October 25th, 1891) has obtained 
from the subcutaneous administration of 
from 3 to 6 deci-milligrammes [2^0 to 1^0 
grain] of atropia a prompt haemostatic action 
in several cases of hsemorrhage, epistaxis 
and hsematemesis, which ergotin and other 
unsual remedies had failed to control. The 
hsemorrhage was always arrested in about 
ten minutes. In one patient the injection 
had to be repeated three times; but in all 
the others one single injection sufficed to 
permanently arrest the loss of blood. Dr. 
Hausmann, of Meran, has also successfully 
resorted to the injection of atropine in haem- 
optysis. Afterward, another German phy- 
sician, Dr. Tacke, of Wesel, found atropia, 
hypodermically administered, an excellent 
method for the arrest of excessive menstrual 
loss. 

The haemostatic action of atropine is ex- 
plained on the ground of an action directly 
the opposite of that pertaining to ergotin. 
While the latter agent causes contraction of 
the capillaries, atropia causes their dilata- 
tion by paralyzing the vaso-constrictor 



nerves, as has been demonstrated by Gra- 
ham Brown. By increasing the quality of 
blood in the general capillary circulation, 
atropine diminishes the afflux toward the 
point of haemorrhage, favors coagulation and 
arrest the haemorrhage. 



TUBERCULIN IN THE TREATMENT OF 
LUPUS. 

Eichhoff (Therap. MonatsL, Sept., 1891) 
relates his experiences extending over six 
months. Of twenty cases of lupus only one, 
occurring in a lad, aged 15, was completely 
cured, there being no relapse in six months' 
time, when the patient was last seen. In a 
second case of lupus acneiformis of the face 
in which the tubercle bacillus was found, a 
fresh set of lupus nodules appeared during 
the treatment. When, however, local treat- 
ment was combined with the use of tubercu- 
lin, the further development of these nod- 
ules was very slight, and the patient was 
discharged in five months' time with nearly 
all of them healed. EichholF would explain 
this by the reaction being insufficient to 
make a way through the skin, and thus time 
and opportunity were given for the absorp- 
tion of the bacilli. This is the danger in 
the treatment, and consequently the lymph 
should be used in conjunction with local 
treatment. Of six cases thus treated two 
relapsed, and of four others treated with 
tuberculin alone three relapsed ; of the re- 
maining ten, part were discharged better 
and part were still under treatment. A 
case of prurigo and another of tuberculous 
eczema (Unna) were cured by the lymph. 
The lymph did not harm the patient in any 
case, and Eichhoff believes it to be a specific 
for lupus (tuberculous) processes, and that 
it does not act favorably on fresh tubercle. 
He says it is neither right to discard the 
remedy nor yet to look upon it as harmless, 
or as acting without fail. — Brit Med. Jour. 



LAVAGE IN VOMITING FOLLOWING CHLO- 
ROFORM. 

Dr. Lienevitch (Rev. Ther. Med. Chir.) 
proposes to relieve the vomiting which fol- 
lows the administration of chloroform, by 
lavage. He believes that not only the chlo- 
roform, but as well the irritation of the peri- 
toneum produced by the antiseptics, is ac- 
countable for this symptom. He employs 
the tube of Faucher and washes out the 
stomach with warm water in which | to 1 
per cent, of bicarbonate of soda has been 
dissolved, until the water returns clear. The 



30 



Periscope. 



Vol. Ixvi 



abdominal walls are compressed (after an 
operation of laparotomy lias been performed) 
during the washing. The results are excel- 
lent, in that, if necessary, water sufficient for 
the needs of the patient can be left in the 
stomach. The general condition improves, 
because there is freedom from nausea, gas- 
eous accumulations, vertigo, and epigastric 
distress. 



SULPHAMINOL, OR THIO-OXYPHENYL- 
DIAMIN: A DISINFECTANT. 

Dr. Wojtaszek communicates to the Frze- 
glad Lekarski some observations he has 
made on sulphaminol, which has been 
brought out by an eminent German firm as 
a new disinfectant, which is said to split up 
Y/ith the body into carbolic acid and some 
compounds of sulphur. So far from this being 
the case, however, Dr. Wojtaszek found that 
large doses might be given to animals, both 
hypodermically and by the mouth, without 
producing any effect whatever ; also that 
when applied as a dressing to cancers, soft 
chancres, and other open sores, it exercised 
no - disinfectant action. He has therefore 
come to the conclusion that for therapeutic 
purposes it is inert. 



TREATMENT OF BUBOES. 

Dr. S. Cordier (Ugeshrift for Laeger, Nos. 
4-5, 1891) punctures buboes as early as pos- 
sible, injects a strong nitrate of silver solu- 
tion into the cavity, and covers the place of 
puncture over with iodoform. Healing soon 
follows. Sometimes the puncture must be 
repeated. 



TREATMENT OF INJURIES TO THE HEAD. 

Dr. Senger, of Crefeld has proposed a new 
method of treatment with the object of facil- 
itating repair in suppurating wounds of the 
head, with exposure of the cranium. He 
first arrests the phlegmonous and puriform 
process by surgical and antiseptic treatment 
— that is, by incisions, drainage, and dress- 
ing, — and so reduces the complicated injury 
to a simple cranial wound, which of course 
still produces a certain quantity of pus every 
twenty-four hours. A wet antiseptic dress- 
ing is then applied to the wound for two or 
three days, and when this is taken off the 
first layer of the tabula externa is removed 
with the help of a small chisel, in little scales, 
until drops of blood are seen in the bone. In 



from two to three days granulations protrude 
from the bone, and entirely cover it in from 
eight to ten daj s, and healing subsequently 
progresses as in other wounds. Suppuration 
ceases in proportion to the growth of the 
granulations. It is also possible to produce 
granulations by drilling several small holes 
in the external table until blood is seen ; 
but the chisel is preferable, as it is difficult 
to estimate the depth of the drillhole, and 
the drilling takes more time than the chisel- 
ling. A still more serious objection to the 
former is that the holes get filled up with 
bone dust. In neither method is it necessary 
to give an ansesthetic, as but little pain is felt 
during the trifling operation. — Lancet. 



OXYGEN INHALATION. 

Neumann {Therap. Monatsh., October, 
1891) says that experiments up to now have 
been concerned with the inhalation of (1) 
as pure oxygen as possible with no increase 
of pressure, (2) a mixture of oxygen (63 
per cent.) and nitrogen under ordinary pres- 
sures and (3) air with high percentage of 
oxygen and with increased pressure, and the 
authors communications refer to this. The 
following conditions must be present: (1) 
the production of the gas must take place 
in a manner which can be observed and reg- 
ulated, (2) the amount of gas must allow 
itself to be approximately calculated with 
each respiration, (3) it must not irritate, and 
therefore (4) it must be mixed with air, and 
(5) it must be inspired under a moderately 
increased pressure. The author then de- 
scribes his apparatus. Patients soon learn 
how to use it. The pulse, at first quickened, 
is ultimately slowed. No unpleasant head 
symptoms arise. There is no palpitation ; 
in fact, the heart's action is regulated. 
Sleep is often induced, even in men. In 
many patients the night's rest has been im- 
proved, the breathing has been rendered 
easier, and there has been a general feeling^ 
of increased strength. In three cases treated 
at the same time by Koch's method, the 
fever disappeared in two, and was lessened 
in the third. The author thinks the action 
of certain drugs as of iron in chlorosis, may 
be increased by oxygen inhalation. He has 
treated very severe cases of anaemia, a case 
of convalescence from pleurisy, cases of 
phthisis, and a case of sepsis and of diabetes, 
with good results, and he appends a few notes 
on them. Neumann thinks it may be of ser- 
vice in gout, as it diminishes the amount of 
uric acid in the urine. — Brit. Med. Jour. 



January 2, 1892. 



Periscope. 



31 



ANTIPYRIN IN AFFECTIONS OF THE 
PHARYNX AND LARYNX. 

M. E. Saint-Hilaire (Archives de Laryn- 
gologie, September, 1891) refers to a recent 
paper by himself and M. Coupard, in which 
they described the therapeutic value of anti- 
pyrin, apphed locally, in certain throat 
affections. By its means they were able to 
cure a variety of complaints dependent on 
undue sensibility of the pharynx and larynx, 
such as spasmodic cough, sensations of prick- 
ing in the throat, or of a foreign body, etc. 
These results seemed due to a local anaes- 
thetic effect of antipyrin, and M. Saint- 
Hilaire has performed numerous experi- 
ments with the view of determining the 
anaesthetic properties of antipyrin. He 
draws the following conclusions from these 
experiments: 1. The anaesthesia produced 
by cocaine is complete, and applies to tactile 
sensation and to sensations of heat and cold. 
2. The anaesthesia lasts from one to two 
hours. 3. In order to produce this effect 
the strength should be not less than 30 per 
cent. The solution employed by M. Saint- 
Hilaire is of a strength of 40 per cent. He 
thinks that autipyrin will be found especi- 
ally useful in cases where a prolonged anal- 
gesia is desired ; thus, in tuberculous ulcera- 
tion, the pain may be kept under by paint- 
ing the parts with the antipyrin solution 
two or three times a day. It will be found 
useful in those affections where either the 
reflex element or the painful element pre- 
dominates. Moreover, antipyrin possesses 
an antiseptic property which will render it 
additionally useful in certain cases. Of 
course, when for the purpose of operation an 
anaesthesia of short duration is required, 
cocaine is preferable, as the effect is more 
rapidly produced, and is more complete 
while it lasts. — Brit. Med. Jour. 



ON THE THERAPEUTIC VALUE OF NERVE- 
STRETCHING. 

Dr. Archiraede Mischi comes to the fol- 
lowing conclusions : 

1. Nerve-stretching constitutes, by its 
manner of action, a special therapeutic pro- 
cess. This influence is felt even as far as 
the nervous centres and in the medulla ob- 
longata in particular. A paralysis of sensa- 
tion, with relative conservation of motility, 
is produced. 

2. Nerve-stretching is an efficacious 
method of treatment in those cases in which 
the lesion is peripheric ; hence, it is useful in 
the treatment of the various neuralgias, tic- 



douleureux, spasms, traumatic contractures 
and reflex epilepsy. 

3. It must be condemned in tabes dorsalis 
and various affections of the medulla oblon- 
gata, in which it is never successful, often in- 
jurious and, finally, sometimes fatal. 

4. It ofl'ers but the slightest probability of 
success in the treatment of tetanus. — II Rac- 
coglitore Medico, Dec. 10, 1890. 



CRESOL SOLUTIONS. 

The question of securing a neutral solu- 
tion of the cresols has been the subject of 
recent investigation, the customi of emulsify- 
ing them by means of soap or alkalies, being 
open to many objections. It has been ascer- 
tained (Chem. Zeit.) that the addition of 
cresol to a very concentrated aqueous solu- 
tion of sodium salicylate, produces a mix- 
ture which may be diluted with water with- 
out fear of the cresol separating on standing. 
This process does not result in the formation 
of any double salt. The ortho-meta or para- 
cresol may be used, and the sodium salicy- 
late may be replaced by salicylates of other 
bases or by the salts of ortho-oxybenzol car- 
boxylic acid, or of the phenols and naph- 
thols, the latter possessing the solvent prop- 
erty in a greater degree than the former. 
Experiments demonstrate the superiority of 
solutions effected by means of sodium creso- 
tinate. A 2 of 1 per cent, solution is said to 
be equally as efficacious for bactericidal pur- 
poses, as a 5 per cent, solution of carbolic 
acid, and to be free from its caustic and irri- 
tant effects. 



MEDICINE. 



OXALURIA AND H.EMATURIA. 

Dr. Francis D. Boyd writes in the Lancet 
that very little is known of the clinical sig- 
nificance of the excretion of oxalate of lime 
in the urine in the condition described as 
oxaluria. Numerous cases of so-called cycli- 
cal albuminuria, accompanied by oxaluria, 
have been described, in which by some 
authors the albumen was ascribed to irrita- 
tion of the kidneys by the crystals of oxalate 
of lime. That some of the albumen in those 
conditions is derived from the urinary tract 
is highly probable, but the following case 
seems to support the view that the excretion 
of crystals of oxalate of lime does irritate 
the kidneys in some cases. 

Mrs. M , a young woman of a very 

rheumatic history, was taken ill during the 
night of July 20th with severe pain in the 



32 



Periscope 



Vol. Ixvi 



lumbar region. She likewise had headache 
and felt very feverish. Next morning the 
pain was easier, though the headache was 
still present, and she noticed that her urine 
had become of a bright red color. There 
was no pain on micturition. He saw her on 
the following day ; she was then complain- 
ing of headache. Pain in back still present ; 
no oedema. First sound of heart loud and 
accentuated. Pulse 100, full, and of rather 
high tension. Urine faintly acid, containing 
blood in large quantities and albumen. 
Under the microscope the deposit was seen 
to be composed of blood-corpuscles, crystals 
of oxalate of lime, and numerous tube casts 
containing epithelial and blood cells, oxalate 
as well as crystals. " On inquiry he found 
that for three days before the attack the 
patient had been partaking largely of rhu- 
barb, which she said she knew never suited 
her. She was directed to take nothing but 
milk, to rest in bed, to keep the bowels 
freely open with Friedrichshall water, and 
nitro-hydrochloric acid was prescribed. On 
the following day there was marked im- 
provement. The pain in the back was gone, 
the blood and casts were decidedly dimin- 
ished, and urine was passed in larger quan- 
tity than formerly. The oxalates were still 
present. By July 26th the blood, albumen, 
and casts had entirely disappeared, and the 
patient was feeling quite well. 

In the Monthly Journal for August, 1849, 
Begbie describes certain cases of what he 
terms the oxaluric diathesis, but in none of 
his cases, though there was pain in the back, 
does there seem to have been kidney irrita- 
tion produced. The passage of the oxalates 
in the case above quoted differ from his, in 
that the oxalic acid seems to have been ab- 
sorbed directly from the stomach, and not to 
have been produced during the process of 
digestion and assimilation. That there was 
in this case a true nephritis he thinks there 
can be no doubt from the presence of the 
casts, and the oxalate of lime crystals seem 
to be the cause, and not a mere concomitant. 



PRIMARY SPLENOMEGALY. 

M. Bruhl (Archiv. GSn. de Med., June, 
1891) describes the disease first called 
splenomegaly by Professor Debove, and 
characterized by (1) hypertrophy of the 
spleen ; (2) progressive anaemia without 
leukaemia ; and (3) absence of glandular en- 
largement. It may begin with general 
symptoms of anaemia, with pallor, fat*igue on 
the least exertion, and debility not unlike 
Addison's disease. More rarely it com- 



mences with pain in the left hypochondrium, 
nausea, vomiting, and even obstinate diar- 
rhoea. These attacks of pain, except for the 
locality, resemble hepatic colic. They are 
due to a perisplenitis. The spleen is en- 
larged, somewhat tender, and the surface 
slightly irregular. Frequently there is a 
pleurisy of the left base. But even in the 
second group of cases, a history of previous 
weakness, loss of color or epistaxis can gen- 
erally be made out. When the disease is 
fully developed the anaemia is not essentially 
different from other forms of anaemia. Ex- 
amination of the blood reveals nothing that 
is pathognomonic. The red cells are much 
diminished in numbers, and the amount of 
haemoglobin may be reduced to one-half. In 
most cases the number of white cells is not 
increased. No micro-organisms have been 
found. The enlargement of the spleen is 
progressive, uniform, and considerable. 
Sometimes the liver is enlarged. There 
may even be an interstitial hepatitis. Diges- 
tive troubles and constipation are usually 
present. Haemorrhages do not often occur. 
Epistaxis is the most common, and, in the 
advanced disease, petechiae may be present, 
especially on the legs. The observations on 
the urine are few and discordant. The 
glands are not enlarged, except on occa- 
sional slight hypertrophy of the mesenteric 
and retro-peritoneal glands. In the last 
stage of the disease cachexia is present ; the 
appetite is lost ; there may be diarrhoea and 
haemorrhages; fever is exceptional. As to 
the course of the disease, it lasts from six 
months to two years, advancing steadily to 
a fatal end. Sometimes, however, it pro- 
gresses by fits and starts, and rarely there 
may be an amelioration or even a quasi- 
recovery. M. Bruhl says that surgical 
interference (splenectomy) has brought 
about a complete cure. The complications 
are pneumonia, perisplenic abscess, and per- 
foration of an ulcer of the stomach or intes- 
tine. Splenomegaly must be distinguished 
from leukaemia, from tumors of the spleen, 
from amyloid disease, and from the enlarged 
spleen "accompanying cirrhosis of the liver. 
In the grave forms of anaemia the spleen is 
rarely much enlarged. — Brit. Med. Jour. 



SYPHILITIC DISEASE OF THE LUNGS. 

Dr. Haslund distinguishes two forms of 
pulmonary syphilitic disease : 1. The diffuse 
form — an increase of the interstitial connec- 
tive tissue. The affection always begins at 
the root of the lung and extends thence 
2. The gummatous form — one or many gum 



January 2, 1892. 



Periscopi 



33 



mata scattered through the lung, except the 
apex, which is rarely affected. Both forms 
often coexist. The course of the disease is 
sometimes very rapid, death occurring in 
from two to six months. In other cases the 
disease causes no symptoms, and the pres- 
ence of pulmonary disease may be discovered 
only at the autopsy. In the early stages 
there are no physical signs ; later on, in 
some cases, dulness on percussion over the 
root of the lung is noticed, and inspiration 
becomes rough and sharp. Toward the end 
respiration acquires a cavernous character. 
Syphilitic lung disease is difficult to diagnos- 
ticate during life. The distinction from 
phthisis is difficult. The diagnostic points 
on which Professor Haslund relies are: 1. 
Absence of tubercle baccilli. 2. Location ; 
the apex is rarely affected in syphilis, almost 
always in tuberculosis. 3. The downward 
progress of the case is much more rapid in 
syphilis without appropriate treatment than 
in phthisis. 4. Absence of fever in the 
earlier part of the disease. 5. History of 
syphilis. 6. Results of antisphilitic treat- 
ment. The prognosis is good if suitable treat- 
ment (mercury and iodide of potassium) be 
adopted in time. The disease is rare. Pro- 
fessor Haslund has, however, diagnosticated 
and successfully treated several cases. 



THE BACILLUS OF ENTERIC FEVER. 

In the Centralblatt /. klin. Medicin, Sep- 
tember, 1891, Dr. Lehmann, when speaking 
of the recent contributions by Dr. Babes and 
M. Cassedebat to this subject, says that com- 
paratively a short time ago a fairly sure 
recognition of the typhoid bacillus, even out- 
side the body, seemed a task easily to be per- 
formed by the help of the culture on the 
potato, but that now it must be looked upon 
as very difficult, if not impossible. When 
this difficulty was recognized, other distinc- 
tive signs were sought for, as, for instance, 
the negative indol reaction, the growth on 
colored media, or upon potato gelatin, but 
none of them are really characteristic. M. Cas- 
sedebat (Ann. de rinstitut Pasteur, 1890, No. 
10) found three kinds of bacilli resembling 
that of enteric fever in the Marseilles drink- 
ing water. He thought he could distin- 
guish them by the color of the inoculation 
into gelatine, by the behavior of old bouillon 
cultures, and by the growth in colored 
media. Dr. Babes (Zeitschrift fur Hygiene, 
Band ix, Heft 2), on the other hand, would 
seem to be no longer in a position definitely 
to separate the nineteen varieties he ob- 
tained from the bodies of individuals dead 



of enteric fever, since he adds that in several 
of the varieties the tendency to lose many 
of their characteristics has been observed. — 
Brit. Med. Jour. 



SPINAL SYMPTOMS OF GONORRHCEAL 
ORIGIN. 

Drs. Spillman and Haushalter (Revue de 
Medecine, August, 1891) reports two cases in 
which spinal symptoms were associated with 
gonorrhcea. In each case the sequence of 
events was (1) pregnancy, (2) vaginitis con- 
tracted in the later months, (3) pains and 
swelling of joints, especially of the knee, (4) 
normal labor, (5) the onset of nervous symp- 
toms. These were violent lancinating 
pains in the extremities, tingling of 
the feet, great muscular atrophy ; the sphinc- 
ters were not, however, affected, neither was 
the sensibility to pricking, touch, or heat 
impaired ; the reflexes also remained intact. 
A bedsore formed rapidly on the sacral re- 
gion. Under treatment, however, all these 
alarming symptoms disappeared, and even 
the atrophy of the muscles was almost en- 
tirely removed by a course of massage, etc. 
The authors are inclined to think that the 
knee swelling was secondary to spinal 
lesions. — Brit. Med. Jour. 



SCLERODERMA. 

From clinical obervations in three cases 
and a post-mortem study of one. Dinkier, 
(Deutches Archiv fur klin. Med., Bd. xlvii., 
H. 5 u. 6) maintains that scleroderma is a 
disease sui generis, characterized at the out- 
set by firm swelling and at a late stage by 
cicatricial-like atrophy of the cutis. The 
swelling is frequently preceded by vasomo- 
tor disturbances. Pigmentation and desqua- 
mation may take place, but are not distinc- 
tive. Scleroderma may be diffused or cir- 
cumscribed. The disease process is not 
restricted to the skin ; it may appear in the 
brain and in striated muscular tissue. The 
etiology of the disease is obscure ; the affec- 
tion may appear spontaneously or it may 
follow acute or chronic injuries. It is ana- 
tomically characterized by hyperplasia of 
the connective tissue and by vascular changes. 
The disease of the vessels involves only indi- 
vidual arterial branches and corresponds to 
periarteritis, mesarteritis and endarteritis. 
Clinical observation and anatomical investi- 
gation render it probable that the disease is 
dependent upon an inflammatory process 
especially involving a varying arterial dis- 
tribution. The prognosis is dubious. Treat- 



34 



Periscope. 



Vol Ixvi 



ment must be constitutional, conjoined with 
the application of the constant current and 
warm baths. 



SURGEHY. 



NEW OPERATIONS ON THE PROSTATE 
AND BLADDER. 

Kiister read a paper on this subject be- 
fore the Deutschen Gesellschaft fiir Chir- 
urgie, 1891, which is abstracted in the 
Centralhlatt fitr Ghirurgie, 1891, No. 26. 
After referring to Kummel's method of 
operating by suprapubic cystotomy for en- 
largement of the prostate, he states that the 
researches of Von Dittel have shown that 
the obstruction to the flow of urine comes 
more often from the lateral lobes than the 
median, and that these can be better reached 
from the perineum than from above the 
pubis. Kiister has operated three times, 
making his incision in the median line of 
the perineum and then transversely around 
the left side of the anus. There is great 
liability of wounding the urethra, and this 
occurred in two of his cases. It can, how- 
ever, by care be avoided. In one case a 
fistula remained which has not yet closed. 
All three patients can void their urine in a 
stream and are very much improved. The 
permanency of the benefit cannot be de- 
termined, as the time which has elapsed 
since the operations is only from two to ten 
months. He also performed a total extir- 
pation of the prostate and bladder in a man, 
aged 53 years, affected with carcinoma of 
the prostate with papillary degeneration. 
The patient was placed upon Trendelen- 
burg's support and the bladder exposed 
above the symphysis. The upper edge of 
the pelvis was chiselled away, as advised by 
Helferich, and the bladder was opened to 
confirm the diagnosis, the cut being again 
sewn shut. With a blunt instrument the 
bladder was freed from the surrounding 
parts and an opening into peritoneal cavity 
closed with sutures. A median incision was 
made in the perineum and the urethra 
divided and the prostate separated with 
blunt instruments and scissors. In order to 
find the ureters more surely, the bladder 
was again opened. After they were exposed 
they were loosely tied and cut obliquely up- 
ward and backward. A few strokes of the 
scissors then freed the bladder. A male 
catheter was introduced into the rectum 
and an opening made. The mucous mem- 
brane of the ureters was sutured to that of 
the rectum, the knots being placed in the 



bowel and additional catgut sutures inserted. 
The wound was tamponed. The patient, 
who had had bronchial catarrh pre\dous to 
the operation, died of a lobular pneumonia. 
The catgut sutures of the ureters gave away 
too soon and allowed urine to flow through 
the wound. Kiister was induced to perform 
thi§ operation by the success which he had 
in the treatment of a case of vesico-vaginal 
fistula by Rose's method. He made a fistu- 
lous communication between the vagina and 
rectum and then closed the vagina. The 
patient was thus enabled to retain the urine 
for tw^o hours in the rectum — Univ. Med. 
Mag. 



SUBMUCOUS RESECTION OF THE INTES- 
TINE. 

Dr. Kummer finds that the chief fault of 
the ordinary suture of the intestine is its 
tendency to cause a stenosis, which may be 
followed by intestinal obstruction, perfora- 
tion, or paralysis. To remedy this disad- 
vantage he has undertaken experiments on 
animals, and was led to adopt the following 
method : He dissects a cylindrical flap of 
mucous membrane, about 1^ cm. long, from 
the transverse section of the gut, and then 
unites mucous membrane with mucous mem- 
brane. The sero-muscular flaps are folded 
back in such manner that the serous mar- 
gins are approximated, and sutured in this 
position. The sutures which in the ordinary 
Lembert suture protrude into the gut are 
placed on the outside of the intestine and 
thus do not narrow the lumen. — Centralbl.f. 
d. gesammte Therapie, Augnst, 1891. 



SPECTROSCOPIC EXAMINATION OF THE 
BLOOD IN SURGERY. 

At the recent French Surgical Congress 
M. M. Henocque and Bazy reported the 
results of a series of examinations of the 
blood with the spectroscope made on persons 
who were compelled to undergo surgical 
operations. According to these investiga- 
tions the demonstration of the quantity of 
hsemoglobine in the blood affords the surgeon 
some valuable information in cases where it 
is necessary to decide whether the patient's 
health is sufficiently good to permit of the 
performance of an operation which may not 
be urgently required. In ovariotomies and 
laparotomies undertaken for the removal of 
tumors it is of advantage to determine the 
degree of anaemia and the condition of nutri- 
tion by this method, so that the operator 
may be able to select the most favorable 
time for operation. 



January 2, 1892. Periscope. 



35 



The authors also made some exceedingly 
interesting experiments with the view of 
studying the effects of chloroform anaesthesia 
upon the quantity of oxy-hseraoglobin in the 
blood and upon tissue metamorphosis. These 
investigations were carried on before, during 
and after the performance of surgical 
operations. It was demonstrated in 
eight cases of major operations that 
chloroform actually tends to augment 
the quantity of haemoglobin in the blood, 
unless a condition of asphyxia is produced, 
and that this quantity may remain station- 
ary despite severe losses of blood. One of 
the constant effects of chloroform ansesthesia, 
however, is to retard the reduction of oxy- 
hsemoglobin ; that is to say, it decreases 
tissue metamorphosis. These phenomena 
therefore illustrate that chloroform does not 
exert a toxic influence on the blood, al- 
though it has a marked effect in retarding 
the vital chemical processes in the body. 
In cases of sudden death at the commence- 
ment of chloroform anaesthesia a complete 
arrest of tissue metamorphosis takes place, 
and to this, in the authors' opinions, should 
be attributed the extraordinary severity of 
this form of syncope. They also believe 
that these facts demonstrate the advantage 
of determining before operation whether an 
individual tendency to retarded tissue meta- 
morphosis be present. 

In our last year's August number we com- 
mented upon some experiments of Prof. 
Mikulicz relating to the same subject. In 
striking contrast to the results obtained by 
M. M. Bazy and Henocque, however. Dr. 
Mikulicz found that the prolonged adminis- 
tration of chloroform produced a decrease of 
hsemoglobine even in operations unattended 
with loss of blood. This fact simply illus- 
trates the wide discrepancy in the results 
obtained by different investigators of the 
same subject. — Internat. Jour. Surg. 



COMPRESSION OF THE CAUDA EQUINA— 
REMOVAL OF A TUMOR— RECOVERY. 

Laquer reports in the Neurolog Central- 
blatt, 1891, No. 7, the case of a young man, 
aged 19, who had been suffering since Sep- 
tember, 1888, from violent pain in the sacral 
region. The patient himself localized the 
pains from the very beginning in the inte- 
rior of the sacral bone. At night, and fre- 
quently during the day, after long continued 
sitting and standing the pains become more 
violent. Finally he had to abandon his 
work, but absolute rest, careful treatment 
and various remedies failed to procure re- 1 



lief. Status in December, 1889 : no impair- 
ment of motor power or of sensibility, no 
muscular atrophy; electrical reactions, deep 
reflexes, vesical and rectal functions normal ; 
no incoordination. The dull, piercing pains 
were so acute at night that they deprived 
the patient of sleep ; they irradiated occa- 
sionally on the posterior surface of the thigh 
doAvn to the fossa poplitea. Galvanic treat- 
ment and chloral gave much relief, so that 
the original diagnosis — neuralgia of the 
plexus sacralis, perhaps neuritis — seemed 
corroborated. But in March, 1890, the 
pains returned and in September very large 
doses of chloral and morphine were of little 
avail. At that time the principal symptoms 
were : strictly localized pain in the middle 
of the OS sacrum, pain on pressure at the 
same spot ; both musculi recti femoris weak 
and slightly atrophied ; transient paresis of 
bladder and rectum ; the knee-jerk abolished 
on one side and very faint on the other ; 
sexual functions feeble ; decubitus on the 
right trochanter; complete absence of all 
inflammatory changes in the vertebral joints 
and in the bones ; no R. D. Due considera- 
tion of the symptoms and the exclusion of 
any disease originating in the rectum or the 
pelvic organs led to the diagnosis of com- 
pression of the Cauda equina caused by some 
neoplasm in the canalis sacralis. Dr. Rehn, 
having opened the sacral canal from the 
hiatus sacralis almost to the last lumbar 
vertebra, corroborated the diagnosis ; for 
he found a soft tumor of the thickness of 
the little finger extending from the middle 
of the sacral bone into the vertebral canal ; 
the tumor w^as extradural, not adherent to 
roots or to the dura mater, but it had exerted 
a strong pressure on the can da equina and 
the dura. Weigert showed the tumor to be 
a lymph-angioma cavernosum. Status three 
months after the operation : The pains in the 
back have disappeared completely. The 
patient sleeps three or four hours in the 
night without an hypnotic. Occasionally 
there are slight pains in the left sciatic nerve. 
He walks for three or four hours without 
fatigue. No vesical or rectal trouble. The 
knee-jerks are easily elicited and are equal 
on both sides. 



GYNJEOOLOGY. 



GONORRHCEA IN THE FEMALE. 

Bumm ( Ceil tr alb latt fur GyndJcologie, 
1891, No. 22), from a long study of this sub- 
ject concludes that gonorrhoea in women is a 
process limited to the superficial layer of the 



Periscope, Vol. Ixvi 



36 

mucosa ; the cocci invade the epithelial 
layer, but are always arrested when they 
reach the sub mucosa. The epithelium is 
originally cast off by reason of the active 
suppuration, but is quickly renewed, assum- 
ing the pavement form ; after this change 
has occurred the active invasion of gono- 
cocci is usually arrested, but they continue 
to grow in the secretion, in which they may 
persist for months and years. The gono- 
cocci have no connection with septic pro- 
cesses ; they do indeed cause suppuration of 
the mucosa, but are destroyed when they 
reach the subjacent connective tissue. If 
sepsis develops it must be in consequence of. 
mixed infection; septic germs are frequently 
present in gonorrhoeal pus, and a favorable 
nidus for the reception of external germs is 
offered by the purulent genital secretion. 
The urethra and cervical canal are the 
favorite seats of gonorrhoeal infection ; acute 
gonorrhoea of the cervix gives rise to symp- 
toms only at the outset, but after it has be- 
come chronic it may exist for years without 
causing disturbances, unless it extends to 
the corpus uteri and thence to the tubes. 

The cocci possess no power of spontaneous 
movement and extend only short distances 
by proliferation. Extension over larger sur- 
faces must be through the agency of the 
secretion. Normally the cervical secretion 
cannot pass the os internum, which also 
serves as a barrier to the entrance of the 
specific infection. Menstruation favors the 
admission of cocci into the uterine cavity, 
also certain mechanical causes, such as coi- 
tus, the introduction of sounds and intra- 
uterine medication ; lastly, this is liable to 
occur during the puerperium. After they 
have reached the cavity they again remaiia 
stationary, and probably are only carried 
into the tubes from the causes already men- 
tioned, the puerperium being the most favora- 
ble time, as the proximal openings of the 
tubes are then more patent. In fifty-three 
patients .with gonorrhoea, who were kept 
under observation for at least five months 
after the initial symptoms developed, the 
cervix was infected in 75 per cent., the cor- 
pus uteri in 15 per cent., and the tubes in 
only 3.5 per cent. 



PRIMARY CANCER OF THE CLITORIS. 

Dr. F.. J. Merkle {Centralhl /. Gynah, 
October 3rd, 1891) observed this disease in 
a woman, aged 61. At the site of the clitoris 
was a tumor of about the size of an apple, 
already beginning to break down. There 
was an indurated gland as big as a walnut 



in the left groin. The tumor of the clitoris 
was removed by means of the thermo- 
cautery. The patient died seventy-three 
days after the growth was removed. At the 
necropsy epithelioma of the clitoris, with 
metastatic deposits in the lymphatic glands, 
was discovered. Dr. Merkle believes that 
the clitoris was most probably the seat of 
the primarj^ disease in this case. 



REMOVAL OF OVARIES FOR EPILEPSY. 

F. Howitz and Leopold Meyer ( Gynah. 
of Obstetr. Meddel., vol. viii, parts three and 
and four, 1891) describe four cases. The 
results are, on their own admission, dis- 
couraging. The cases were under observa- 
tion for from two and three-quarters to four 
years. In all the ovaries were more or less 
diseased. In one case only was the patient 
cured. The fits increased during pregnancy. 
In the second the same symptom was ob- 
served, but after the operation the patient's 
condition was but slightly improved. In the 
third and fourth no improvement followed 
lactation, yet in the third the epileptic fits 
had always increased in number and severity 
during catamenial periods, and from thirteen 
months after the operation no show ever ap- 
peared. In the fourth the fits had ceased for 
four years, and recurred when the patient 
was suckling. All the four patients had 
been subject to fits for over seven years, the 
first or successful case having been epileptic 
for thirteen years at the least. In three out 
of the four complete amenorrhoea followed 
the operation. In the third there was a 
typical irregular haemorrhage from the sixth 
to the thirteenth month after the oophorec- 
tomy. — Brit. Med. Jour. 



OBSTETRICS. 



LABOR IMPEDED BY PARASITIC FOETUS. 

Dr. Westerschulte (Nouvelles Archives 
d' Obstet et de Gynec, August 25th, 1891) 
was called in to a labor case by a midwife, 
who could not deliver the child though its 
head was already born. He found that the 
child was half born, its trunk being exposed 
as far as the umbilicus. He relaxed the cord 
and then attempted to extract the child, 
which was still living and had passed the 
seventh month of intrauterine hfe. Though 
he used much force the trunk remained 
fixed, and he began to suspect tmn preg- 
nancy with adhesion of the twins. He 
placed the patient across the bed, and on 
careful exploration detected a soft mass 



January 2, 1892. Periscope. 



37 



behind the breech, which felt like a second | 
bag of waters. After firm traction for about 
a quarter of an hour the child was suddenly 
delivered. It made a few feeble respiratory 
efforts, but could not be kept alive. A big 
cystic body hung down from the child's 
breech ; it was double the size of the head, 
and contained a placenta-like structure and 
a piece of cartilage an inch and a half long. 
The child was a well- formed male ; there was 
no anus, the rectum opening into the cyst, 
which clearly represented a parasitic foetus. 
— Brit. Med. Jour. 



THE TREATMENT OF POST-PARTUM HEM- 
ORRHAGE BY MEANS OF THE DUHRS- 
SEN UTERINE TAMPON. 

In the Therap. Monatshefte Dr. Everke 
writes that post-partum haemorrhages are 
either due to lacerations of the vaginal mu- 
cous membrane and cervix, or else they 
arise from the uterine cavity when this organ 
does not contract firmly after expulsion of 
the foetus (atonia uteri). The hsemorrhages 
of the first variety can always be controlled 
by sutures, but the cases of uterine atony in 
which no efiTect is produced by using ergotin, 
compression, or rubbing with the hand re- 
quire other treatment. Diihrssen's method 
of using the tampon is the surest, simplest, 
least dangerous, and most readily carried 
out of all the methods. The technique is as 
follows; The hair about the pubes is to be 
carefully scrubbed with soap and water, the 
vagina washed out with a thirty-per-cent so- 
lution of carbolic acid or a sublimate solution 
of one to one thousand. For tamponing we 
employ from three to six metres of ten-per- 
cent iodoform gauze, eight centimetres wide. 
The left hand grasps the uterus and presses 
it downward ; then (when no speculum is 
employed) the gauze is pushed up through 
the cervical canal with the right hand (em- 
ploying two fingers) to the fundus. In a 
short time we feel a board- like contraction 
and the haemorrhage ceases. The tampon is 
removed at the end of twenty-four hours. 
The author explains the action of the tampon 
in this way : that the raw material produces 
an irritation of the uterine muscle, the con- 
tracting organ presses its walls firmly against 
the tampon, the lumen of the vessels becomes 
closed, and .the haemorrhage ceases. (It is 
consequently not advisables to tampon the 
uterus too firmly). The tampon may also 
be employed in cases of puerperal haemor- 
rhage and in slight lacerations. 



MORRENIA BRACHYSTEPHANA— A NEW 
GALACTAGOGUE. 

Senhor Pedro N. Arata describes (Revista 
Farmaceutica, Buenos Ay res. No. 5, 1891) 
the chemistry and properties of the above 
plant, which is a member of the Asclepi- 
adacece growing in the Argentine Kepublic 
and other parts of America. An infusion of 
the roots has long enjoyed a local reputation 
as a galactagogue, and the author has en- 
deavored to determine the active principles 
to which such action may be due. For this 
purpose he made the following examination : 
(1) Extraction with ether : Nothing but a 
small quantity of chlorophyl, fatty acids, 
and resin could be obtained by prolonged 
maceration of the powdered root with this 
solvent. (2) Extraction of residue by alco- 
hol : An alcoholic extract of the remaining 
root was made. Of this a portion (resin) 
was insoluble in water, the remainder form- 
ing a red solution, which contained malate 
of calcium, chlorides of potassium and 
sodium, and a substance giving alkaloidal 
reactions with the ordinary tests. No 
volatile alkaloids were found, the only other 
noteworthy substances separated being 
starch, albumen, and gum. By the Stas- 
Dragendorf method the alkaloid could be 
obtained as a dark reddish mass, of pleasant 
odor and very bitter taste, soluble in chloro- 
form, water, and amylic alcohol. An ac- 
curate analysis of this substance could not 
be made owing to the small quantity avail- 
able. (3) Active principles of the fruit 
juice: From the expressed juice of the 
fruit there could be obtained small quanti- 
ties of the same alkaloid together with a 
glucoside. This latter substance is prob- 
ably closely allied, though not identical, 
with a glucoside isolated by List from 
Aselepias cyriaca. The author does not ap- 
pear to have yet worked out the physio- 
logical action of either of these substances, 
but, from an experience with a fresh in- 
fusion of the root, he is inclined to believe 
that the plant has valuable galactagogue 
properties. — Brit. Med. Jour. 



PAEDIATRICS. 

IODOFORM VAPOR IN WFIOOPING-COUGH. 

At a meeting of the Societe Medicale des 
Hopitaux on July 17th (Eev. Gen. de Clin, 
et de Ther., July 22d, 1891), M. Chante- 
messe read, in the name of Dr. Chibret, of 
Clermont-Ferrand, a communication on the 



Periscope. Vol. Ixvi 



38 

effect of iodoform vapor in the treatment of 
whooping-cough. The method consists in 
sprinkling the room in which the patients live 
with iodoform. Under this treatment, 
children presented a marked diminution in 
the frequency of the paroxysms, and the 
duration of the disease was shortened. No 
symptoms of poisoning were observed. — 
Brit. Med. Jour. 



TREATMENT OF DIPHTHERITIC AND 
DIPHTHEROID CONJUNCTIVITIS. 

Abadi {B,ev. Mens, des Mai. de VEnf., 
August, 1891) writes that in the literature 
concerning the treatment of ophthalmia 
there is nothing precise which is to be found. 
Some advise the use of nitrate of silver, 
others warm, and others iced compresses. 
Others still recommend a great variety of 
antiseptic solutions. In most cases the eyes 
have been lost, cures being exceptional. 
Since Fieuzal and Coppez recommended the 
use of lemon-juice for this disease, the author 
has frequently made use of it, and always 
with satisfactory results. It was used fear- 
lessly, for it was believed to be harmless to 
the cornea. During the three or four days 
in which the disease is most threatening it 
must be used every five hours, night and 
day. Subsequently the intervals can be 
lengthened to eight, then to twelve hours, 
and then it can be discontinued altogether. 
This treatment is useful not only in pure 
diphtheritic forms of the disease, but also in 
the diphtheroid forms. It is believed that 
nitrate of silver is very injurious in the 
treatment of this disease. 



CLINICAL AND BACTERIOLOGICAL STUDY 
OF SCARLATINOUS ANGINA. 

In a careful arud conscientious thesis, Dr. 
Bourges divides the angina of scarlet fever 
into the erythematous variety, which may or 
may not be accompanied by a pultaceous 
deposit, the pseudo-membranous and the gan- 
grenous forms. The pseudo-membranous 
may be subdivided into precocious or tardy, 
the first of which is often benign, does not 
extend, and produces little or no effect upon 
the general condition. Late pseudo-mem- 
branous angina, on the contrary, would seem 
to be most often of diphtheritic character, 
although the occurrence of very benign ex- 
amples leaves this point doubtful, and a de- 
cision can only be reached by bacteriological 
investigations. The gangrenous form is the 
most severe, and is accompanied by special 
characteristics. 



His experiments with the inoculation of 
streptococci found in scarlatinous angina 
have led him to conclude that " the anginas 
of scarlatina are due to a secondary infec- 
tion by pyogenetic streptococci in the ery- 
thematous angina, in most cases of precoci- 
ous pseudo-membranous angina, and in cer- 
tain cases of tardy pseudo-membranous an- 
gina." The streptococci found in the sup- 
purations which so often complicate scarla- 
tina generally enter the system through the 
tonsils, which are infected from the begin- 
ning of the disease. — Revue de Laryngo logic, 
etc., Aug. 1st, 1891. 



HYGIENE. 



SANITARY TRIUMPHS. 

In an interesting article in the June issue 
of the American Statisical Association's 
quarterly publication, we find some signifi- 
cant facts regarding the advantages of sani- 
tary legislation experienced in England 
within the past sixteen years. In the year 
1875 a general law was passed in England 
for the protection of the public health, 
known as the Public Health Act, and from 
that time the death rate in England has de- 
creased for all diseases which owe their ori- 
gin and growth to defective drainage and 
impure water supply. Typhoid fever is such 
a disease, and the diminution of 57 per cent, 
in the death rate from this malady is un- 
doubtedly the greatest triumph for sanitary 
reformers. During the ten years from 1866 
to 1865 the annual mortality was 22.19 per 
thousand inhabitants; and from 1838, the 
first year of careful registration, to 1865, 
the average annual rate was about 22.35 per 
thousand. But for the ten years of the period 
1880 to 1889 the average falls to 19.08. It 
seems justifiable to ascribe this diminution 
in the death rate to the operation of the 
Public Health Act, and the execution of 
duties such as drainage, inspection of water- 
supplies, vaccination, and others which are 
becoming better understood. Mr. Farr, in 
his Vital Statistics, estimates the value of 
human life in England to be about $770 a 
head ; that is, the value inherent in the 
people as a productive money-earning race. 
If we suppose, which is allowable if other 
things remain the same, that this diminution 
of the death rate during this last decade 
was due to the measures taken to that end, 
we find that the number of lives saved, rep- 
resenting a total for the decade of 856,804 
persons, according to Mr. Farr's estimate 



January 2, 1892. Periscope. 



39 



represents a social capital of $650,000,000. 
Thus in ten years the country has more than 
regained the sum that was spent in sanitary 
improvements in the fifteen years, and in 
this calculation nothing figures for spared 
grief, better health and happier life. This 
diminution of mortality is not observed in 
in all forms of disease. The mortality from 
zymotic diseases, from 1861 to 1870, was 
42.54 per 10,000 living and this was reduced 
to 24.52 in the period from 1880 to 1889, 
but measles, diphtheria, whooping-cough 
appear to have escaped the in- 
fluence of sanitary measures. Consump- 
tion has equally diminished in Eng- 
land in these last years. The mortality 
from this cause in the years 1861 to 1870 
was 24.89 per 10,000 living. For the 
period 1880 to 1889, it fell to 17.36. The 
statistics further demonstrate that sanitary 
measures affect the death rate of young per- 
sons between the ages of one and twenty-five 
years, and especially between ten and 
twenty years. The gain in this latter de- 
cade, which amounts to 28 per cent., is 
economically a great gain. The death rate 
for old persons has increased during the last 
decade, a fact which may be chargeable to 
the bustle of the nineteenth century, the 
wear and tear upon the nervous system, 
while the effect of sanitary improvement is 
most noticeable in the abatement of infant 
mortality. — Amer. Analyst 



THE INFLUENCE OF WEATHER ON DIS- 
EASE. 

We may regard it as certain that an ap- 
parent connection between infectious dis- 
eases and atmospheric conditions had sug- 
gested itself to the medical mind long be- 
fore Sydenham attributed to the atmosphere 
an " epidemic constitution." The influence 
of weather would be measured by its effect 
in providing an environment suitable to germ 
development. Thus moist weather, whether 
bleak or warm, would be found condu- 
cive to the spread of contagia, and 
so it is. This fact has often been at- 
tested by the extension of cholera, diar- 
rhoea, and the exanthemata. A warm and 
dry day, on the contrary, tends to check 
morbid action of an infectious kind. This 
fact is susceptible of more than one explan- 
ation. We may, on the one hand, regard it 
as a consequence of the absence of that germ 
fortering condition — humidity; on the 
other, we cannot fail to be reminded that 
dry warmth and sunshine give the signal for 
an exodus from many crowded homes, 



for their freer ventilation, and con- 
sequently for diminution in the intensity 
of contagia. The exact value of weather 
changes in regard to this class of diseases, 
however, still is and must for some time re- 
main subjudice. As for the ailments more 
usually associated with these changes — those 
for example, more commonly known as in- 
flammatory — the connection is here much 
more evident, and also in all likelihood 
more direct. The association of pneumonia, 
bronchitis, asthma, and rheumatism with 
bleak and wet weather is too invariable to 
permit of our doubting its reality apart from 
any suggestion of septic agency. — Lancet. 



MEDICAL CHEMISTRY. 



LINAMARIN. 

MM. J orissen and Hairs {Journ. de Phar. 
d'Anvers) have obtained from Linum usita- 
tissimum a nitrogenous glucoside, which 
differs from amygdalin and laurocerasin, and 
is the source of the hydrocyanic acid which 
that plant disengages abundantly under cer- 
tain conditions. Linamarin occurs in the 
form of colorless and odorless needles, 
having a very cooling and bitter taste. Is 
soluble in its weight of water, also in alcohol, 
but almost insoluble in ether. It is distin- 
guished from amygdalin by several physical 
and chemical characteristics, which are 
summed up in the following comparative 
tables : 

LINAMARIN. 

Very soluble in cold 
water, (equal parts). 

Retains its water at 
120° C, melts at 184°, 
and bears a heat of 150° 
without decomposing. 

Not colored by strong 
sulphuric acid. 

Contains 47.88 per cent, 
of carbon, and 5.55 per 
cent, of nitrogen. 

Reducible by adding a 
linseed emulsion, but not 
by one of almond oil. 

No benzaldehyde in re- 
duction products. 



AMYGDALIN. 

Little soluble in cold 
water, (1 part in 12). 

Parts with its water at 
120° C. melts and de- 
composes at 200. 

Colored purple by 
strong sulphuric acid. 

Contains 52.51 per cent, 
of carbon, and 3.06 per 
cent, of nitrogen. 

Is reducible by adding 
an emulsion either of al- 
mond oil or of linseed oil. 

Benzaldehyde present 
in reduction products. 



ON THE PRESERVATION OF LUNAR 
CAUSTIC. 

M. Bartle, pharmacist of the Vincennes 
Military Hospital, after an exhaustive study 
of the matter, concludes that coriander seed, 
linseed, etc., usually used in the preservation 
of lunar caustic are more or less deleterious, 
and recommends in their place powdered or 



40 



Clippings and News Items. 



Vol. Ixvi 



shredded asbestos that has previously burned, 
or thoroughly dried, well-dried sand, or, by 
preference, granulated pumice stone. To 
obtain the latter it is only necessary to beat 
the commercial pumice stone in a mortar, 
and to sift it through a brass sifter in such 
manner as to get the grains about the size 
of shot used for bottle cleaning. The fine 
dust is gotten rid of by sifting in the usual 
way. 



Clippings and News Items. 



THE ASSOCIATION OF MILITARY SUR- 
GEONS OF THE NATIONAL GUARD 
OF THE UNITED STATES. 

The second annual session of the Associa- 
tion of Mihtary Surgeons of the National 
Guard of the United States mil be held at 
St. Louis, April 19th, 20th and 21st, 1892. 
An interesting programme of addresses by 
prominent surgeons of the National Guard 
and the United States Army has been 
arranged, and a goodly number of scientific 
papers on Mihtary and Accidental Surgery 
will be read and discussed, and all matters 
pertaining to the health, usefulness and wel- 
fare of the civilian soldiers will receive at- 
tention. 



COCAINE IN NERVOUS ASTHMA. 

Prof. Da Costa recently treated with 
marked success a case of pure nervous 
asthma with one-fourth grain of cocaine per 
diem. After obtaining the desired result the 
remedy was given only twice afterward, and 
but once a day. 



SALICYLIC ACID AS A DIURETIC. 

After a series of investigations on this 
subject, Huber concludes that salicylic acid 
is one of the safest and most important diu- 
retics. The greatest increase in the amount 
of urine seems to occur in rheumatic fever 
and serious pleurisy, whether the tempera- 
ture is raised or not. In all cases the total 
loss of water by the skin and urine was in- 
creased, and the solids of the urine were in- 
creased. In ordinary pleurisy, and in four 
cases of cardiac dropsy the drug acted well. 



SODIUM SALICYLATE IN RENAL COLIC. 

M. Fay, in the' Wiener Med. Blatter, 
praises the beneficent action of sodium 
salicylate in the treatment of nephritic colic. 
He declares that under its influence the cal- 



culi are rapidly eliminated and the patients 
restored to health. If trucy this is indeed a 
boon to suffering humanity, as few tortures 
are so acute as those of renal colic, and 
none have hitherto been more rebellious to 
treatment. Sodium salicylate has also been 
highly recommended in hepatic colic. 



LA GRIPPE. 



The " grip " 
When you get it 
You'll fret it 
As it wears you 
As it tears you 
You'll abuse 
While you lose 
Your grip ; 
Not the same, 
'Cept in name. 

As that other diabolic, pathogenic and 
prodromic, mucous quirking, top-knot 
wracking, jointlets cracking, stomach- 
working, body-burning, brainpan murk- 
ing, nerves all churning affliction which 
is called — 

Or by £esthetic people bawled 

The " influenza " but, for short 

When with cold in head you snort 

And your temper's on the snip 

It's just ordinary " grip." 

And its metabolic 

Worse than colic 

Poison's in your blood 

And you wish your name was mud. 

Until in sullen fury you let everything 
just rip — 

While in doleful chorus groaning 

Your family are moaning 

In a sort of runic rhyme 

With their vitiated chyme 

The solo of the grip. 

Not the pip 

But the grip, grip, grip 
From its talons you can't slip 
But must sit and in your person 
(For all its woes a curse on) 
Exemplify its rule ; 
And every one's a fool 
When the whisky bottle's drip 
And the quinine mixed you sip 
And pay out pelf 
To rid yourself 
Of that all-effecting 
Naught-delecting 
Old world rip, 
The grip. 

— Phila. Press. 



Vol. LXYI, No. 2. 
Whole No. 1819. 



JANUARY 9, 1892. 



$5.00 per Annum. 
10 Cents a Copy. 



A Weekly Journal. 



Established in 1853 by S. W. BUTLER, M. 0. 

THE 

MEDICAL AND SURGICAL?- 



REPORTER 



EDWARD T. REICHERT, M. D., Editor. % 

Entered as Second-Class matter at Philadelphia P. 0. P. 0. BOX 843, PHILA., PA. 



CLINICAL LECTURES. 

Jules Simon, M. D., Paris, France. 

The Treatment of Typhoid Fever in Children. 
M. D. Mann, M. D., Buffalo, N. Y. 

Chronic Pelvic Peritonitis — Laceration of Cer- 
vix with Retroversion and Partial Prolapse. . 
COMMUNICATIONS. 

Mont. Linville, M. D., New Castle, Pa, 

The Importance of Blood-Clot in Treating 

Dead Spaces 

Charles B. Williams, M. D., Philadelphia, Pa. 
A Case of Thermic Fever Complicated by 

Croupous Pneumonia 

De Forest Willard, M. D., Philadelphia, Pa. 
Fractures and Injuries of the Spine in the 
Cervical Region, Fracture of the Third Verte- 
bra, Cervical Spinal Hsemorrhage, Fracture of 
Odontoid, Fracture of Fourth Vertebra. . . 
J, M. Baldt, M. D., Philadelphia, Pa. 

Supra- Vaginal Hysterectomy 

SOCIETY REPORTS. 

Philadelphia County Medical Society. . . . 

SELECTED FORMULA 

EDITORIALS. 

Peroxide of Hydrogen in the Treatment of 

Diphtheria 

CORRESPONDENCE 

BOOK REVIEWS 



PERISCOPE. 
Therapeutics, 

The Treatment of Haemoptysis — Hypodermic 
Injections of Corrosive Sublimate in Diphtheria 
and Scarlatina — Mouthwash for Carious Teeth 
— Osmic Acid in Goitre — Quinine Poisoning — 
Treatment of Pneumonia in Diabetics — Cures 
for Drunkenness — Treatment of Uraemia — The 
Treatment of Senile Gangrene — Antipyrin in 
the Treatment of Chorea — Tuberculin in Laryn- 
geal Phthisis — Local Anaesthesia Produced by 
Injection of Water — Yeast in Enteric Fever. . 
Medicine. 

Spontaneous Shedding of the Nails in Diabetic 
Patients — Meniere's Vertigo and the Semicir- 
cular Canals — Artificial Neurasthenia— Syphil- 
itic Diseases of the Spinal Column — The Origin 
of Effusions — Goitre: Its Pathology, Diagnosis 
and Treatment — Clinical Study of the Con- 
dition of the Heart in Typhoid Fever. . . , 
Surgery • . . . . 



63 



70 



Gynecology. . 75 

Obstetrics 76 

Pediatrics 77 

Hygiene 79' 

Medical Chemistry 79 

CLIPPINGS AND NEWS ITEMS 80 



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THE 



MEDICAL AND SURGICAL 
REPORTER 



No. 1819. 



PHILADELPHIA, JANUARY 9, 1892. 



Vol. LXVL— No. 2. 



Clinical Lecture. 



THE TREATMENT OF TYPHOID FEVER IN 
CHILDREN* 



BY JULES SIMON, M. D. 

PARIS, FRANCE. 

Gentlemen : — By a mere coincidence there 
have just been admitted to our wards, four 
children suffering from typhoid fever, and I 
will take the opportunity to study with you 
the treatment of this disease in children. 

Our little patients present different types 
of the affection. I will here state that the 
treatment varies somewhat according to the 
forms of the malady, and that certain typh- 
ical conditions require especial management. 
I will refer to this point later, perhaps at the 
conclusion of the lecture. In the meantime, 
I will remark that the treatment of typhoid 
fever, in my opinion, is subject to certain 
rules, rules which I will present to you in a 
synthetical form. In the first place we will 
examine the forms of the disease in our pa- 
tients, and then direct our attention to the 
line of treatment which we shall pursue in 
each one of them. 

The first patient is a boy, 13 years of age, 
who entered the Hospital on the 15th day 
of the disease. Up to this time the disorder 
had followed a regular course, and the pa- 
tient exhibited a marked eruption of rose- 
colored spots. According to certain authors 
these rose-colored spots appear on children 
with the same regularity as they do in adults, 
and that the eruption exhibits the same con- 
fluent form. Up to the 20th day everything 
went on regularly with our patient, but at 
this time there occurred a sudden change ; 
the temperature was, considerably lowered, 
and there appeared what may be called a true 
urinary crisis, the increased amount of urine 
being 1500 grammes in twenty-fours hours. 
In fact, the patient had entered into a condi- 

•5^-Delivered at " Hospital des Enfants-Malades," 
Paris. 

41 



tion of convalescence. On the following 
morning, however, that is on the 21st day 
of the disease, there came, entirely unforseen, 
an abundant intestinal hseraorrhage. Intes- 
tinal haemorrhage in typhoid fever in chil- 
dren is of rare occurrence, it being due, I 
believe, to the fact that in these patients 
Peyer's patches are not generally hard, infil- 
trated with lymphatic elements, and that 
there are no sloughs produced which on be- 
ing detached give rise to hemorrhage. In 
children Peyer's patches are simply exul- 
cerated. Although rare, as I have re- 
marked, intestinal haemorrhage may appear 
under two distinct conditions and offer a 
quite different diagnosis. In certain in- 
stances, as in this case, the haemorrhage is 
unaccompanied by serious symptoms. The 
general condition of the child remains good, 
the frequency of the pulse is comparatively 
unimportant, and there is no marked eleva- 
tion of the bodily temperature. Haemor- 
rhage constitutes, therefore, in these cases, a 
peculiar kind of crisis. I have seen many 
examples of this critical haemorrhagic condi- 
tion, but I can positively state that I have 
never observed any serious symptoms de- 
velop. On the other hand, when the haem- 
orrhage is threatening in an individual in 
whom the temperature is high, the pulse fre- 
quent, and in whom there is a general ady- 
namic condition of the system, then haemor- 
rhage is extremely serious and is generally 
follo\Yed by death. In these cases the haem- 
orrhage is due to marked alteration of the 
blood, and may always be considered as a 
phenomenon of approaching dissolution. 

In our patient the haemorrhage occurred 
under the most favorable circumstances, and 
I, therefore, adopted the following treatment : 
Ice upon the abdomen ; two enemata each 
containing four to five drops of laudanum, 
to be injected in the twenty-four hours; 
cooling lemonade drinks; a mixture con- 
taining 1 gramme of the tincture of the per- 
chloride of iron. I also advised absolute 
rest and a diet of cold broths. As I had 
reason to expect, the results have been most 



42 



Clinical 



Lecture. 



Vol. Ixvi 



excellent. The convalescence of our young 
patient has been steady, and to-day (the 
28th of the disease) he is doing as well as 
could be desired. The hsemorrhage stopped 
three days ago, and he has commenced to 
partake more or less of a nourishing alimen- 
tation. He will be advised to continue the 
perchloride of iron during the period of con- 
valescence. 

The point I wish to impress regarding this 
particular case is, that the occurrence of 
haemorrhage should not be a cause of de- 
spair. If the general symptoms are favora- 
ble, you must not fear to push the treatment 
I have indicated, with a right to expect and 
obtain a happy issue. 

The second patient to whom I wish to call 
your attention, exhibits a type of abortive 
typhoid fever, in which the symptoms ceased 
about the 15th day, notwithstanding that the 
disease is apparently ready to avert or pro- 
duce at the same time serious troubles. The 
patient is nine years of age, and entered our 
service on the 1 8th day of the disease, with 
all the typical phenomena of a mild typhoid 
fever. In this, as in the majority of chil- 
dren, no prodromic symptoms were observed, 
notwithstanding that the period never fails to 
appear. This prodromic period,which we have 
never noticed in this Hospital, will be most 
frequently met with in your civil practice. 
In children, it is true, this period of typhoid 
fever presented phenomena characterized by 
symptoms of a generally mild nature. The 
patients show a peevish disposition, sujffer 
from irregular attacks of headache, perhaps 
one or two during the day. There may be 
a slight reaction, of a short duration ; and, 
finally, with the appearance of a capricious 
appetite, there may come on a change in the 
usual character of the patient. You must 
be careful, however, in studying the differ- 
ent signs in order to avoid errors ; for while 
you may be assuring the parents of the child 
of the commencement of a typhoid fever, 
you may be really dealing with a simple 
catarrhal affection. Again, you may attrib- 
ute the symptomatology to an approaching 
attack of abortive typhoid fever, especially 
if the general aspect of the patient is not in 
accord with the rest of the symptoms, par- 
ticularly with the elevation of temperature. 
If the general condition of the child is good, 
and there is an increased bodily heat, the 
probability is that you are contending with 
an abortive form of the malady. Apropos 
of this, I will state that in children the tem- 
perature rises easily, sometimes going up as 
high as 40°C., under the influence of the 



slighest emotion. It behooves us, therefore, 
not to suspect the existence of typhoid fever 
simply on account of the high temperature. 
You have seen, it is true, in our patient an 
evening temperature of 40°C., appearing 
constantly for seven consecutive days, and, 
nevertheless, convalescence has been estab- 
lished; but at the same time, the pulse, 
which had been exceedingly frequent, has 
fallen to 90 pari passu with the disappear- 
ance of the other symptoms. 

Our third patient shows another type of 
typhoid fever. Not only the usual symp- 
toms have been developed in this case, but, 
besides, other symptoms of an ataxo-adyna- 
mic character have been manifest. In the 
presence of these nervous symptoms I have 
thought best to treat the case by the hydro- 
therapic method. The result of this treat- 
ment has been most favorable. At this 
time I have no longer insisted on the appli- 
cation of baths, although I have always for- 
mulated this treatment in general. The 
child is to-day in a good condition, and con- 
valescence has been completely established. 

Our fourth and last patient to-day, is a 
typical case of typhoid fever, without com- 
plications or any anomalous character. In 
cases like this I advise a general treatment 
of which I desire to speak to you, a treat- 
ment that I invariably employ in regular, 
uncomplicated cases of typhoid fever in 
children. 

In the first place hygiene must be at- 
tended to. As soon as the correct diagnosis 
is made I order the patient to remove to a 
new habitation, and a change of bed cloth- 
ing morning and night. At the same time 
I order bathing, evening and morning, of 
the whole body, with aromatized water 
(thymol or cologne) at a temperature of 
30° C. If the bodily temperature is elevated, 
say to 40° C, I order this bathing to be ap- 
plied with even more frequency if the heat 
of the body should show a tendency to in- 
crease. This bathing is to be made by means 
of a sponge, and rapidly, first over the 
anterior and then over the posterior part of 
the body, after which the patient should be 
rapidly wrapped up in order to obtain a 
slight reaction. 

This sponge bathing, I repeat, I am in 
the habit of employing in every case, and I 
especially recommend it to be applied fre- 
quently in cases of high temperature, and 
only when there are manifest no serious 
phenomena of a nervous character. On the 
contrary, when symptoms of an ataxo-ady- 
namic nature accompany the elevation of 



January 9, 1892. Clinical 



Lecture. 



43 



the temperature, then I have recourse to the 
application of general cold, or better warm 
baths. 

I will not to-day study from a general 
point of view the question of the employment 
of cold baths in the treatment of typhoid 
fever, nor especially how such a measure 
acts in the case of adults. I will confine my 
remarks to the consideration of my method 
of treatment in the case of children and of 
the results that I have obtained. If, for 
instance, I observe in a child, at the same 
time, a high bodily temperature and ataxo- 
adynamic phenomena, I prescribe from the 
beginning baths at a temperature of 35° C, 
of a quarter of an hour duration, progress- 
ively diminishing the temperature of the 
baths to 25° C. The baths are renewed 
every three hours, but this rule is not abso- 
lute, and generally our guide should be the 
march of the disease, particularly in regard 
to the amount of fever. The baths then, 
should be renewed according to the degree of 
the hyperthermic condition of the patient. 
This practice which, I assure you, has noth- 
ing of a dogmatic character, has given me 
good results, and you have observed a good 
example in the case of our third patient. 
Therefore, to conclude, in children you 
should always advise the application of cold 
baths in those cases especially that exhibit 
ataxo-adynamic symptoms, but abstain from 
ordering them when there is only a condition 
of hyperthermia. I will repeat, that a high 
temperature by itself is of no consequence 
in the case of children. To this therapeutic 
measure (generally applied in all cases), you 
will add an enema, night and morning ; if 
the stools are oflfensive you will order an in- 
jection of berated water slightly aromatized. 
For drinks, lemonades or some mixture with 
syrup of orange should be given. The diet 
should consist, during the febrile period, of 
broths. You have not heard me speak of 
milk. The reason is that, according to my 
experience, milk is not an entirely proper 
article of food in the typhoid fever of chil- 
dren. With few exceptional cases, milk is 
badly digested and its administration is fol- 
lowed by a slight exacerbation of fever. 
Therefore, I prefer to give it during the 
period of convalescence. In advanced stages 
of the disease, I prescribe claret, rum, brandy 
or Malaga. 

Such is the hygienic treatment which I 
apply to typhoid children ; but the medic- 
inal treatment is as equally important. If 
the young patient is laboring under a state 
of agitation, I prescribe the following 
mixture : 



Jpk; Hydrate of chloral gramme 0.50. 

Tincture of musk git. xx. 

Linden-tree water grammes Ixxx. 

Syrup of orange flowers grammes xx. 

This to be administered in dessertspoonful 
doses in the course of 24 hours. 

I prefer chloral to the bromide of potass- 
ium on account of the digestive disturbances 
which the latter remedy is apt to produce. 
If the child complains of headache, I give 
small doses of the syrup of codeine ; but 
bear in mind that this is the only opiated 
preparation which is to be employed in in- 
fantile typhoid fever. The extract of quin- 
quina which is frequently used in the enteric 
fever of adults, ought not to be administered 
to children. In fact, I will state that the 
extract produces disorders of digestion and 
provokes a loss of appetite, especially for 
those articles of food most advantageous to 
these young patients. 

At the beginning of the 15th day of 
the disease, I prescribe the perchloride 
of iron in the following manner : At 
first, 1 drop every two hours, afterwards 
double the dose for about two or three days. 
This remedy can be given in a little water, 
sweetened or not, after the first mouthfuls of 
broth. Once taken, the child is allowed to 
finish his cup of broth. The perchloride of 
iron is a very valuable remedy in the treat- 
ment of infantile typhoid fever. It has 
given me, in a large number of cases, very 
good results. The medicament acts not only 
as a tonic, but it also appears to aid diges- 
tion, and thus, it is entitled to its continued 
administration during the period of conval- 
escence. I insist upon the use of the per- 
chloride of iron, and you will do well in pre- 
scribing it also. 

I have said nothing so far in regard to 
the use of quinine. I have purposely left 
for the last my remarks about this drug. In 
all cases of infantile typhoid fever you must 
administer, from the very beginning, the 
sulphate, and you must continue it during the 
whole period of the disorder. You will 
cease its ingestion only when defervesence 
has been completely established. The doses 
of the drug will vary according to the age 
of the patient and the physiological efiects 
produced. — Translated from ie Bulletin 
Medical, Nov. 15th, 1891. 



In consequence of the remarkable success 
claimed in the treatment of drunkenness 
with hypodermic injections of strychnine, 
this method of treatment was tried in the 
city hospital in Gorlitz, Silesio, but the 
results were almost entirely negative. 



44 



Clinical Lecture. 



Vol. Ixvi 



CHRONIC PELVIC PERITONITIS— LACER- 
ATION OF CERVIX WITH RETROVER- 
SION AND PARTIAL PROLAPSE. 



BY M. D. MANN, M. D., 

PROFESSOR OF OBSTETRICS AND GYNECOLOGY UNI- 
VERSITY OF BUFFALO — ATTENDING GYNi^;COLO- 
GIST TO THE BUFFALO GENERAL HOSPITAL. 



Gentlemen : — This woman has come to get 
an opinion. She is twenty-four, has been 
married six years, has had no children. 
She was first unwell when sixteen. She 
has menstruated at intervals sometimes of 
four weeks, sometimes of three, sometimes 
she flows a good deal, sometimes very 
little. Since she has been married there 
has been more flowing. It was not painful 
when it first began but it has been so since 
marriage. She first began to feel ill five 
years ago. She had the ague and then 
scarlet fever during the first year of her 
married life and she had never quite re- 
covered her strength. She complains of 
pain in her side. She says she has had a 
kind of paralytic stroke affecting the left 
side and even now her left arm is not as 
strong as it was. The same condition ob- 
tains in the left leg and foot. The stroke 
came on suddenly while she was walking. 
She did not become unconscious but she 
could not talk for three or four days. She 
was almost totally incapacitated for a week 
or two and for four or five months she was 
quite weak in the side and could do very 
little work. 

The pain of which she now complains, 
begins in the left ovarian region and runs 
through to her back. It is worse when she 
is unwell and especially just at the conclu- 
sion of menstruation. Her period lasts some- 
times three or four days, sometimes two 
weeks. She does no work except about her 
house, and even that tires her a great deal, 
and she has to lie down frequently^ during 
the day. Her bowels are regular except 
that sometimes she has to use an injection. 
The movements are sometimes quite painful. 

You hear the history of this case and it is 
sufficiently common and characteristic. 
Here is a woman who is in comparatively 
good health until she gets married. Then 
she has a sickness in her first year of married 
life from which she recovers slowly, follow- 
ing this she has what she calls a stroke of 
paralysis from which she recovers but grad- 
ually and partially. About a year ago her 
health again began to fail. She complains 



of pain in the ovarian region, backache and 
general inability to work. What can we 
say as to the diagnosis of such a case? It 
might be almost anything. We cannot 
make a diagnosis although we might imag- 
ine what the condition is. Just before I 
brought her into clinic, I made an examinar 
tion and I found that on the left side of the 
pelvis behind the broad ligament, there was 
a mass of something which did not belong 
there. I could feel this through the vagina 
and by examining through the rectum I 
could feel it very distinctly. Pressure over 
this mass from the inside caused a great deal 
of pain and when I made bi-manual palpa- 
tion she evidently was hurt considerably. 
There could be but one thing, with this 
history and with what I find by physical ex- 
amination to account for her trouble, and 
that is some pelvic inflammation. It is a 
little difficult to trace the history of it and 
to know exactly when it began but prol^a- 
bly there was a specific origin for it since 
the trouble increased greatly soon after 
marriage and she never has been regular in 
her menstruation since marriage, and since 
then she has flowed a good deal more. 
Probably there was an old gleet existing in 
the husband at the time of marriage or 
perhaps a more recent urethritis. It 
is impossible to tell at this late 
date just how the trouble originated. 
However that may be, she has been a great 
deal worse since the attack a year ago. The 
pain and sufifering referred to the left side 
has made her a miserable invalid since then. 
What is the significance of the pelvic mass 
which I have felt in my examination? It 
does not mean a pelvic cellulitis, as we used 
to think, but a pelvic peritonitis having its 
origin in the Fallopian tube. I cannot tell 
you its exact cause, but I can tell you its 
nature. The Fallopian tube is inflamed, 
prolapsed, knitted together Avith the ovary 
into a mass by adhesions and bound to the 
broad ligament behind. On the other side 
we can feel little or nothing, and there is no 
tenderness.' At the same time, there may 
be a less degree of trouble there. The pel- 
vic peritonitis is very apt to be worse on one 
side than on the other. It is very rare to 
find one side diseased and the other entirely 
healthy. 

The important question is, what we can do 
for the patient. She is poor and her hus- 
band depends upon her to manage the house. 
It is exceedingly necessary for her and him 
that she should have her health and be able 
to work. It is a question almost between 
the poor-house and health. What can we 



January 9, 1892. Communications. 



45 



do to help this woman ? These cases of pel- 
vic inflammation are very difficult to handle. 
There is not, in all probability, a pus tube in 
this instance. The mass that I feel is quite 
small, very hard, it is not low down in the 
pelvis and does not give the impression of a 
large distended tube but of a thickening of 
tissues and agglutination to other parts by 
peritonitis. At the same time it causes a 
great deal of local and reflex pain. There 
is also intercostal neuralgia which goes so 
commonly with these troubles, although 
women often think that the pain is due to 
heart disease. There is a very close nervous 
connection between the left ovary and the 
intercostal nerves, as was pointed out by 
Fothergill a number of years ago ; there is 
a direct channel for reflex disturbances. 

This woman has had a certain amount of 
treatment but it has done her little good. 
She has been treated at the Dispensary a 
year with local applications, douches, iodine, 
tampons, etc. When she first came she 
could scarcely walk and for a few months 
she was benefited, but of late she has made 
no progress. She probably will not improve 
further on such treatment. I do not know 
anything further to do, unless it be to try 
electricity or perform laparotomy. I have 
not been satisfied with the use of galvanism 
in the treatment of these cases. It may be 
because I do not know how to use it, or it 
may be because it does not do any good. I 
have tried it myself and I have seen it tried 
by those who claim to be experts in its use 
and without improvement on the part of the 
patient. A long course of " rest cure " 
might do this woman some good, but it is 
absolutely beyond her means. I do not see 
anything left except a laparotomy and I 
should expect that by the removal of these 
diseased organs the patient would be allowed 
to regain her health. The function of the 
organs is, of course, destroyed so that the 
tube could not carry an ovum, but the ovary 
probably cannot even give off" an ovum. The 
woman would much rather have her health 
than the exceedingly remote possibility of 
bearing children. I shall suggest to her an 
operation, telling her frankly that I do not 
know anything else that will cure her. The 
risk of laparotomy is comparatively slight 
and the chances of good results very great. 



Pyoktanin, though no better, perhaps, 
than corrosive chloride or some other articles 
to prevent wounds becoming septic, is, how- 
ever, much better to disinfect a wound which 
has become septic or infected. 



Communications. 



THE IMPORTANCE OF BLOOD CLOT IN 
TREATING DEAD SPACES* 



BY MONT. LINVILLE, M. D., 

NEW CASTLE, PA. 



Since the days of Ambrose Pare the prog- 
ress of surgery has been steadily onward and 
upAvard. History is full of illustrious 
names ; but in the years to come the name 
of Lister will stand out more prominent 
than all others. In teaching us the impor- 
tance of cleanliness and the use of antisep- 
tics and the drainage tube, he has not only 
conferred the greatest boon on sufiering 
humanity, but gave medical men of the pres- 
ent day an impetus to learn how to assist 
nature in healing wounds without interfer- 
ing with her laws. 

In olden times the blood was considered 
the plastic material which filled the holes 
' like the glue and cement which stick to- 
gether the edges of a wound, but now we fear 
the most dangerous results from its decom- 
position, and use our best efforts to keep a 
wound free from it, and the surgeon who fails 
to check haemorrhage will look in vain for 
successful results from his antiseptic tech- 
nique. But when we change our views on 
any question, the pendulum of thought often 
swings too far in the opposite direction. 
May we not have fallen into the same error 
on this subject. 

For more than twenty years the eyes of 
every thinking surgeon have been turned 
towards the great Lister, who has never lost 
an opportunity to emphasize wound drain- 
age, and he is still untiring in his efforts to 
discover the best means for so doing. But 
during the last eight years other great minds 
have proposed methods for healing wounds 
without drainage tubes. Seven years ago 
Neuber contributed an interesting article on 
this subject. He recommended irrigation 
with a sterilized solution of salt, and drain- 
age by loose stitching. To get rid of dead 
spaces he advised buried sutures inverted 
stitches, flap implantations and compression 
from without, but this plan is not only tedi- 
ous, but often impossible to thoroughly oblit- 
erate the dead spaces in wounds. 

I have worked until I was nearly ex- 
hausted in trying to carry out this plan of 

*Read before the Association of the Surgeons of 
the Pennsylvania Railroad Company in Chicago, Oct. 
20th, 1891. 



46 



Communications. 



Vol. Ixvi 



treatment, but I do not believe that I ever 
thoroughly succeeded in obliterating the 
dead spaces. More than once in such cases 
I have been surprised and gratified to find 
that the wounds healed by the first intention 
just as regularly as the most simple wound 
without dead spaces. 

Recently my mind has conceived the idea 
that there is something in Schede's theory 
of wounds healing under the moist blood 
scab. 

He says, " It has required only a moder- 
ate experience with antiseptic surgery to 
enable us to recognize that even large blood 
clots in open wounds do not necessarily 
undergo destruction or decomposition, that 
they do not necessarily give rise to inflam- 
mation and accidental diseases, but that they 
take on changes which we may designate as 
organization of the blood clot, and which 
one may compare with the conversion of the 
thrombus in ligated blood vessels." This 
calls to my mind the words of the immortal 
John Hunter, which I first heard when a 
student from the lips of that grand old man 
Professor Gross : " In many deep-seated 
wounds where all the parts have remained 
in contact, those underneath will unite much 
better if the surface be allowed to scab. 
Compound fractures [more especially where 
the external wound is small] should be 
allowed to heal in the same way; for by 
preventing the blood to scab upon the wound 
either by itself or when soaked in lint, the 
parts underneath will unite, the blood under 
the scab becomes vacular, and the union 
will be complete even when the parts are 
not in contact. Many wounds ought to be 
allowed to scab in which this process is now 
prevented ; and this arises, I believe, from 
the conceit of surgeons who think them- 
selves possessed of powers superior to nature, 
and therefore have introduced the practice 
of making sores of all wounds." 

Gentlemen, the author of these words was 
certainly far in advance of his time. I am 
aware that I stand on debatable ground, and 
that many may assail my position, but I 
only claim to be an humble learner, and if 
I can provoke a discussion on the few points 
which I may be able to hint at in this short 
paper, perhaps I maybe able to absorb some 
practical knowledge that will pay me for my 
long journey to this meeting. 

I honestly believe that the blood clot is 
the important factor in healing many wounds 
where we have dead spaces. And that too 
many surgeons do harm by trying to get rid 
of it, by the use of drainage tubes, and the 
application of strong antiseptic solutions. 



Do not understand me to say that I am 
opposed to antiseptics or the use of drain- 
age tubes. I believe that it is our first and 
most important duty, to thoroughly antisep- 
ticize our hands and the external portion 
of the wound, but we meet with many cases 
where the wound is deep, with large dead 
spaces, that I believe the use of carbolic 
acid or corrosive sublimate destroys the 
physical and, perhaps, the chemical charac- 
ters of the blood, and produces a superficial 
necrosis which must retard healing. In 
operations upon diseased bones, where it is 
impossible to remove every particle of dis- 
eased bone or tissue, and where a profuse 
discharge is sure to follow, I am in favor of 
drainage, but in all wounds where the cavity 
is composed of healthy tissue, I believe that 
nature is superior to a drainage tube. In 
amputations if we cut our flaps short and 
neat, stitch the muscles and close the flaps 
by buried skin sutures there is no reason 
why we should not have rapid healing by 
first intention. I will very briefly relate the 
history of a few cases which I have treated 
during the last three years. 

Case I. — Miss W., age 55, consulted me 
last September for carcinoma of right mam- 
mary gland; the tumor extended across 
the sternum and the axillary glands were 
involved. I found it necessary to remove 
the breast, pectoralis fascia, a large portion 
of the pectoralis major, the glands and 
adipose tissue in axilla, and skin fascia and 
muscles down to the sternum and ribs, three 
inches wide and five inches in length, this 
portion of the wound was without a covering, 
and presented a frightful appearance, I per- 
mitted the wound to fill with a blood clot, 
after which it was dressed antiseptically. I 
did not open it for a week, when I found 
the blood clot organized and a healthy 
scab covering the entire wound, which was 
completely healed in twenty-eight days. 
The patient has gained twenty pounds and 
thus far there is no sign of a return of the 
disease. 

Let me digress for a moment, while I say 
that experience teaches me that the only 
hope of permanent cure in carcinoma of the 
mammary gland is not only to remove the 
entire gland but the axillary glands and a 
liberal portion of the surrounding tissue. 
Even the pectoralis major muscle nearly up 
to its insertion into the arm. 

Case II. — Railroad brakeman injured 
while coupling cars. There was a compound 
comminuted fracture of the right arm, in- 
volving the elbow joint, which felt like a 
sack of small bones ; the skin was broken 



January 9, 1892. Communications. 



47 



through in five places; there had been pro- 
fuse haemorrhage but was checked, or nearly 
so, by blood clots when I saw the patient. 
The arterial circulation being good 1 de- 
cided to make an effort to save the arm. 
I enlarged the wounds sufficient to remove 
lacerated pieces of muscles, and fragments 
of the humerus, olecranon and condyles of 
elbow joint. I then placed the arm in a 
solution of corrosive sublimate one to one 
thousand for several minutes ; by this time 
the clots which had been broken up were 
reformed. No stitches were used, the arm 
after being dressed with iodoform gauze and 
loose bandage was placed on a straight 
splint. I redressed it in five days and found 
the blood clots red and healthy, and that 
they would bleed if gently touched with a 
probe. In four weeks the wounds were 
healed, and although the arm is weakened 
he has good motion in the joint. 

Case III. — A German merchant, who 
was an excessive beer drinker, consulted me 
four years ago on account of a running sore 
on the anterior portion of right leg. I 
found that the anterior portion of tibia was 
diseased about three inches in length, also 
the soft parts for a much larger circumfer- 
ence. I removed every particle of diseased 
bone and tissue with a curette, and allowed 
the cavity to fill with a clot. I then ap- 
plied the usual dressing, and on the fourth 
day found the clot was organized and 
healthy; this case gradually progressed to 
complete recovery. The cavity was filled 
so as to make the limb smooth and natural. 

If time permitted I could relate several 
cases of compound fracture of the leg where 
there was not only loss of bone, but of the 
soft parts over the seat of the fracture, in 
which nature repaired the injury by organ- 
ized blood-clot. 

The dressing of this class of wounds is an 
important matter ; gutta-percha tissue is an 
excellent protection, and enables the surgeon 
to avoid injuring or tearing away the scab 
during subsequent dressings. The old habit 
of dressing wounds every day or two, and 
each time tearing the wound open by so 
doing, was barbarous and I often wonder 
that nature did not rebell with such empha- 
sis as more frequently to prevent recovery. 

The less we disturb a wound the better ; 
in all favorable cases of amputations one or 
two dressings should be sufficient. In the 
past much harm has been done, and many 
limbs and even lives have been sacrificed 
by tight bandaging. I am glad that this 
matter is being constantly agitated. We 
always know better, but it is so easy to over- 



do it that we constantly need to be reminded 
of the danger. 

• The buried suture in many cases is a great 
improvement. How often have w^e found 
the holes in the skin produced by the 
stitches full of matter, and the wound healed 
by first intention. The skin, no matter how 
thoroughly disinfected, may contain the germs 
for producing septic trouble, but the cavity 
of a wound if in a normal condition may be 
capable of disposing of large quantities of 
micro-organisms. 

A' frequent cause of suppuration in in- 
fected wounds is obstructed circulation, and 
nothing is so liable to cause it as tight liga- 
tures and sutures. Experience teaches me 
that I haye committed more than one sin 
against nature in this way during the early 
years of my practice. Methinks it a good 
plan to use weak silk, and if we occasionally 
break it we are reminded that we are using 
too much force. 

I hint at these small matters, because they 
all belong to the one great family in wound 
treatment, and it will not do to neglect the 
most minute detail if we wish for reasonable 
success. 

We may be successful in treating wounds 
with dead spaces, either by obliteration, 
drainage or blood clot, providing we thor- 
oughly disinfect the skin and everything that 
touches the patient. 

In conclusion let me say that while I do 
not recommend dispensing entirely with the 
drainage tube, there is a strong tendency in 
that direction among some of the bright sur- 
geons of to-day. We love to boast that sur- 
gery is a true science, but we never should 
forget that nature is the great physician, and 
that the best we can do, is to assist her in 
the simplest manner possible. 

The blood clot theory is not new. It is 
being tried here and there by progressive 
men who are loud in its praise. We live in 
the age of rapid thought, and the physician 
who loves the profession, and works for 
something more valuable than money, must 
be devoted to hard study and extensive read- 
ing. 

The multiplicity of ideas requires him to 
have a clear brain and quick judgment if 
he wishes to stand somewhere near the front 
rank, and to be a blessing to suffering 
humanity. I am reminded of the lines often 
quoted by the August Nestor : 

" A wise physician our wounds to heal. 
Is more than armys to the public weal. " 

And again those quoted by Paulus from 
that grand old poet Homer : 



48 



Communications. 



Vol. Ixvi 



" The man of medicine can in worth with many 
warriors vie, 

Who knows the weapons to excise, and soothing 
salves apply. " 



A CASE OF THERMIC FEVER COMPLI- 
CATED BY CROUPOUS PNEUMONIA. 



BY CHARLES B. WILLIAMS, M. D., 

RESIDENT PHYSICIAN, PENNSYLVANIA HOSPITAL, 
PHILADELPHIA. 



John P. L., age 27, white, a vigorous, 
healthy looking man, employed at Spreckles' 
sugar refinery, having been overcome by the 
heat was brought to the Penusylvania Hos- 
pital by the police patrol on June 17, 1891, 
during the service of Dr. Morris J. Lewis. 
On admission at 2.35 P. M. his temperature 
per rectum was 110°; pulse 160; resp. 42. 
He was intensely cyanosed about the face 
only. The rest of his body was burning 
hot to the touch. His eyes were markedly 
congested — the pupils were contracted and 
the eyeballs were rolled upwards. He was 
in a state of profound unconsciousness. 

His breathing was rapid, stertorous and 
labored and accompanied with a loud 
rattling in his throat. His bowels were 
moving involuntarily when he was brought 
in and moved continuously for 20 minutes 
after admission. He had had convulsions 
before admission but none after. His pulse 
was scarcely perceptible at the wrists. It 
could be counted at the carotids and by the 
stethoscope. There was a profuse, frothy, 
mucous discharge from his nostrils. 

At 2.35 P. M. he was given an iced 
enema and an hypodermic of tr. digitalis 
n^^x with whiskey tt^^xv. His bowels con- 
tinued to move for some time after the iced 
enema had been given. At 2.55 P. M. his 
temperature had fallen to 103f ° ; pulse 160 , 
resp. 52. He was given another hypodermic 
of digitalis and whiskey. At 3.10 P. M. his 
temp, and pulse were the same but his res- 
pirations were 40 per minute. He was now 
given an hypodermic of strychnise sulph. 
gr. eV- At 3.20 P. M. the first sign of reac- 
tion occurred. His temp, was 102|° ; pulse. 
136 ; resp. 32. It was now that the ice rub- 
bing produced a marked redness over his 
body surface, and the spraying from the 
hose would cause him to writhe and twist 
about ; for previous to this, while the ice 
and hose were being applied he had remained 
quite immovable. Between 3.20 and 3.35 
P. M. the hose was again applied. His 



temp, at 3.35 P. M. was 102^ ; pulse 124; 
resp. 34. The hose was now appHed for the 
last time between 3.35 and 3.50 P. M. At 
3.50 P. M. his temp, had fallen to lOOf ° ; 
pulse 110; resp. 28. He was now thor- 
oughly dried and placed upon another bed. 
At 4.05 P. M. his temperature was 99° ; 
pulse 120 ; resp. 32. He seemed very rest- 
less and was writhing and twisting about 
the bed a great deal. He was accordingly 
given an hypodermic of morphias gr. \ et 
atropine gr. lio- At 4.20 P. M. temp, was 
981° ; pulse 132 ; resp. 32. At 5 P. M. his 
pulse still continued to be very rapid and 
feeble. Ordered another hypodermic of tr. 
digitalis n\^x and whiskey tt^^xv. At 5.20 
P. M. his temp, arose to' 104°; pulse 120; 
resp. 32. Had another hypodermic of 
digitalis and whiskey. At 5.45 P. M. his 
pulse still remained unchanged. Ordered 
him hypodermics of whiskey every fifteen 
minutes until 8.30 P. M. From 6 P. M. 
until 8.30 P. M. he seemed very restless and 
twitchy and he was therefore given an- 
other hypodermic of morphise gr. i. During 
this time he also received two more hypo- 
dermics of tr. digitalis and whiskey. His 
pulse could now be distinctly felt at the 
radials. 

As he still continued very restless, his 
wrists and ankles were strapped to the bed. 
When the patient was removed to the ward 
at 8.30 P. M. he was still in an unconscious 
condition. He was ordered to have an ice 
cap to his head and hypodermics of whiskey 
every half hour until 11 P. M. After 
which time he had them hourly with spts. 
ammon. aromat. f 3 ss. by mouth. The pa- 
tient slept through most of the night and 
awakened in the morning and desired to 
know where he was — how he had come to 
be in the Hospital and why the straps were 
on his wrists and ankles. Temperature was 
now 991° ; pulse 98 ; respiration 18. His 
pulse was rather feeble and although his 
general condition was remarkably improved 
yet he seemed rather dull and slept a good 
deal. His urine examination now showed a 
specific gravity of 1022 — was clear, yellow, 
acid and contained albumen. Microscopical 
examination showed numerous hyaline and 
epithelial with pale granular casts. 

On the following day, 19th, he seemed 
muddled and dull of comprehension and 
when asked a question he would reply in 
such a manner as almost to indicate that he 
had been having a little too much spiritus 
frumenti. His pulse was 84 and of fair vol- 
ume, and respiration 28. His stimulus and 
digitalis were immediately discontinued and 



January 9, 1892. Communications. 



49 



he was given sodii brom. gr. xv. t. d. and 
also calomel gr. \ et sodii bicarb, gr. v. q s. 
h. The following note was made on this 
day : There is no left knee-jerk and none on 
reinforcement. His feet have a curious 
mottled appearance. He has good power 
and grip in both hands. His face draws up 
more on the right side than on the left. His 
tongue comes out straight, but possibly it 
turns a trifle towards the left. There is no dif- 
ence to be seen in the movement of his fore- 
head. He can read understandingly, and 
speaks in a thick voice as if he had some- 
thing in his mouth. Right pupil is a trifle 
larger than the left. Pupils react to light 
and accommodation. He has a slight elbow 
jerk. On June 21st he became delirious and 
continued so more or less until the end of 
the month. He had numerous delusions and 
hallucinations and could not be reasoned 
out of them. His temperature during this 
time ranged between 99°-|- iii the morning to 
102-3 and 4+ in the evening. On the 27th 
he began coughing a good deal. His sputum 
was profuse, greenish, muco-purulent and 
tenacious. On July 1st physical examina- 
tion of his chest showed that fremitus was 
most marked over his right chest anterior. 
Percussion note good and very resonant ; 
expiration over right chest was rather pro- 
longed with a few cooing rales. Posterior — 
right base, percussion note is flat, tubular 
breathing, segophony and sub-crepitant 
rales. Three days later the following note 
was made: Percussion note is still flat over 
the right lung posterior, tubular breathing 
and sub-crepitant rales can be heard in the 
right spinal gutter. Of late his temperature 
has been keeping close to the normal in the 
day time with an evening rise to 103° or 104°. 
-\- His temperature usually begins to rise 
from 6 P. M. to 11 P. M., when it reaches the 
maximum 104°. Antikamnia in repeated 
doses of gr. jss and gr. iij seemed to have no 
effect in controlling this rise of temperature. 
The same could be said of antipyrin and 
quinine. The latter drug having been ad- 
ministered as high as gr. xxxvi. per diem. 
Urine examination made on July 10th, 
showed a specific gravity of 1018, w^as clear, 
yellow, slightly acid, albumen and casts neg- 
ative, some triple phosphates. 

In addition to the above drugs the 
patient was receiving ammon. carb. gr. v. 
every four hours besides milk punch t. d. 

On July 18th the following note was 
made : Chest — There is good movement an- 
terior and but slight impairment in reson- 
ance at the right apex. A few moist rales 
can be heard posterior on the right side and 



mostly at the root of the lung. He per- 
spires profusely at night and especially after 
the small doses of antikamnia. 

On the 16th of August his chest seemed 
to be perfectly clear, and his temperature 
has been keeping within the limits of 1011°. 
The attack of croupous pneumonia caused 
the patient to emaciate rapidly but after his 
chest began to clear up and his cough had 
ceased he soon commenced to regain his 
strength and weight. 

On September 4th, his temperature 
reached normal and showed no inclination 
to rise after that time — his cough had ceased 
entirely and he seemed to be in perfect 
health. He was discharged cured, on Sep- 
tember 19th, 1891. 

The patient's temperature chart is a curi- 
osity. It is 8 feet 2 inches in length and its 
record covers a period of three months with 
the exception of two days. In all of this 
time the patient's temperature never reached 
the normal to stay any length of time until 
a few days before his discharge, when it 
showed no inclination to rise again and he 
left the Hospital — a picture of health. At 
the present time the patient is doing well 
and he has no return of bad symptoms. 



FRACTURES AND INJURIES OF THE SPINE 
IN THE CERVICAL REGION— FRAC- 
TURE OF THE THIRD VERTEBRA- 
CERVICAL SPINAL HAEMORRHAGE, 
FRACTURE OF ODONTOID, FRAC- 
TURE OF FOURTH VERTEBRA.-^- 



BY DE FOREST WILLARD, M. D., 

SURGEON PRESBYTERIAN HOSPITAL; CLINICAL PRO- 
FESSOR ORTHOPEDIC SURGERY UNIVERSITY OF 
PENNSYLVANIA, PHILADELPHIA. 



The following group of injuries to the 
spine, taken in connection with the cases of 
laminectomy reported by me in the Trans- 
actions of the College of Physicians, Philadel- 
phia, January, 1890, and February, 1891, 
show that the prognosis in the majority of 
the cases of injury to the spine is determined 
almost entirely by the initial lesions — i. e., 
the amount of injury which has been pri- 
marily inflicted upon the cord. In nearly 
all cases of spinal fracture the substance of 
the cord receives severe contusions or lacer- 
ations, and the resultant symptoms are not 
only dangerous, but it frequently happens 
that death ensues in a short time. 

*Read before the Philadelphia County Medical 
Society, December 9th, 1891. 



50 



Communications. 



Vol. Ixvi 



The first case shows that even very posi- 
tive bone injury in the cervical region may 
produce symptoms of but moderate severity, 
provided the cord be uninjured. 

Fracture of Third Cervical Vertebra. — E. 
R., male, aged thirteen years, fell through 
an elevator shaft some thirty feet. He was 
picked up unconscious and removed to the 
Hospital. Upon examination a large hgema- 
toma was discovered over the occiput, but 
there were no external evidences of injury. 
The head was retracted and turned markedly 
backward ; it could be bent only slightly 
from side to side. Rotation was possible 
only to a slight degree. A finger passed 
into the mouth discovered a distinct promi- 
nence behind the posterior wall of the 
pharynx corresponding to the third cervical 
vertebra. The rigidity of the ueck muscles 
was great. There was no paralysis, no 
cough, no loss of sensation, nor could crep- 
itus be discovered. There was no evidences 
of severe pressure upon the cord. Flexion, 
extension, and rotation were almost impos- 
sible. 

Under strong extension and counter-ex- 
tension applied upward from the head and 
downward from the body the deformity was 
markedly reduced. A plaster-of-Paris collar 
applied while extension was maintained was 
accurately fitted, so as to keep the head in a 
fixed position. This bandage was arranged 
so as to press on the occiput as high as the 
prominence, also to press upon the mastoid 
and temporal bones, and to curve forward so 
as to encircle the lower jaw. It then accur- 
ately fitted the neck from whence it extended 
to the shoulders and passed down loosely to 
envelop the upper part of the thorax. This 
maintained the head accurately in position 
and prevented any movement of the upper 
portion of the trunk, neck, or head. This 
was applied in place of extension and 
counter-extension on account of the sensitive 
condition of the hsematoma over the occiput. 
After the tenderness from the blood tumor 
had disappeared, weight and pulley exten- 
sion were applied to the head and feet up to 
the point of comfortable endurance. The 
plaster envelopment was sawn open and per- 
mitted to remain as a splint to prevent 
lateral rotation and flexion. 

He was kept in this position for six weeks. 
There was no impairment of motion or sen- 
sation during this time. The extension ap- 
paratus was then removed and an accur- 
ately fitted neck splint of plaster-of-Paris 
was applied. He wore this with comfort six 
weeks longer. At the end of this time ex- 
amination of the pharynx showed that while 



there was still a slight prominence in the 
posterior part of his throat, the deformity 
was much less evident than at the time of 
the injury. There was still less rigidity, 
but no deviation of the vertebral column 
could be discovered. The absence of pressure- 
symptoms resulting from the injury was a 
point of special interest. A year later he 
could move his head in all directions, 
although motion of the chin to the right was 
limited. Flexion seemed perfect. It is but 
seldom that a patient either breaks or dislo- 
cates his neck without more serious symp- 
toms. 

Cervical Spinal Haemorrhage. — W. M., 
aged eighteen years, was injured by diving 
eighteen feet into a pool of water two feet 
deep. He struck his head and the back of 
his head on the bottom of the pool. He was 
immediately pulled out by his comrades and 
was found to be unconscious. He remained 
in this state two hours. When first seen, 
some time after, he was blanched and pale, 
and complained of a pain in the back of his 
neck and beneath the shoulders. Sensibility 
was present throughout body and legs but 
apparently diminished. There was no opis- 
thotonos, and no rigidity of the neck other 
than that motion gave slight pain. There 
was no tenderness over the region of the 
spinal cord, except slight pain in the lower 
cervical region. There was no visible dis- 
placement of the vertebrae, and no positive 
evidence of dislocation or of fracture. Flex- 
ion, extension, and rotation of the head were 
perfect and accompanied with only slight 
pain. The spinal column could be flexed 
and extended normally. Motion and exten- 
sion in both arms, body, and legs seemed in 
good condition, except as regards sensibility 
as above noted. 

He was partially conscious and could 
answer questions intelligibly, but with an ap- 
parent effort of the will, and his speech was 
slow. There was ansesthesia of both hands, 
especially on the ulnar side. He complained 
of pain in the region indicated. There was 
constant and decided priapism. 

This condition continued until about seven 
hours after the accident, when he slowly 
seemed to lose power of the hands and fore- 
arms on both sides, commencing apparently 
in the region supplied by the ulnar nerve. 
Also there was progressive loss of sensation 
in both hands and forearms. Both brachial 
plexuses were sensitive to the touch, but not 
painful. Priaprism still continued, but the 
urine was voided naturally. The scrotum was 
anaesthetic and remained so for several 
days, and uncertain areas of the abdomen 



January 9, 1892. Communications. 



51 



seemed in the same condition, but his 
answers to questions were not very satisfac- 
tory. The legs retained both motion and 
sensation although both functions were ap- 
parently diminished. 

The patient seemed to rouse from his un- 
consciousness at the end of the first hour and, 
was moderately intelligent. 

Up to this time extension made upon the 
spinal column by means of the head gave 
relief from pain, therefore, an extension and 
counter-extension apparatus was applied to 
the head and extremities, and continued 
traction was maintained. 

Loss of motion and sensation increased 
during the next twenty-four hours until the 
patient was able only to move his arms 
feebly ; fingers immovable. Sensation was 
entirely absent in both hands in the region 
supplied by the ulnar nerve. Sensation was 
impaired in other regions of the forearm and 
hands. 

During the next two days there was ap- 
parently no change either as regards motion 
or sensation, but on the following day both 
functions began slowly to return. 

At the end of the fifth day he could raise 
his arms, but only for a moment. When 
the extensor muscles were required to fulfill 
their functions the arm immediately fell. 
There was still a tendency to priapism, but 
the condition was not constant, the scrotum 
was still ansesthetic. Temperature, pulse, 
and respiration remained unaltered. 

Continuous extension was maintained, and 
as there was no paralysis it was deemed 
probable that all hjemorrhage within the 
canal had ceased. 

Motion and sensation returned to a slight 
degree in the thumb and fingers of the hand 
and in the arm, until gradually both func- 
tions were restored almost entirely. The 
scrotum remained ansesthetic for ten days. 

Fifteen days later he could grasp an 
object with considerable firmness. 
• A trapeze was rigged over the bed so as to 
exercise the arms while extension was being 
maintained. An ischio-rectal abscess dis- 
charged for two weeks and then healed. 

In eight weeks had thoroughly recovered 
and presented no abnormal symptoms. Mo- 
tion and sensation complete. 

A peculiar condition regarding this case 
was that after the condition of shock had 
passed away there was no serious symptoms 
until the probable occurrence of hsemorrhage 
had begun to make pressure upon the spinal 
cord and thus to interfere with its functions. 
The occurrence of paralysis upon both sides 



instead of upon one, and the length of time 
after the injury showed that the symptoms 
must have been largely due to gradual com- 
pression. 

Fracture of the Odontoid Process of Axis 
with Dislocation of Atlas. — C, aged 18 years, 
fell 20 feet, striking uj^on his head. He was 
picked up stunned, but soon regained con- 
sciousness. He was able to walk to his 
home, several blocks distant, and to talk 
with his friends. An hour and a half later 
he was perfectly rational, talked freely and 
pleasantly, and complained of no pain when 
at rest ; he simply desired to be permitted to 
sleep. He was quiet, but would suddenly 
start with an anxious look. The trunk and 
extremities were cold ; pulse 85, feeble. 
Pupils equal, but failed to respond readily 
to light. The head was thrown backward 
with the occiput to the right, but he com- 
plained of no pain. The chin protruded, 
and the thyroid gland was prominent. Any 
movement or rotation of the head toward 
the right was accompanied with pain. Mo- 
tion to the left was painless for a quarter of 
a circle, but any greater motion caused dis- 
comfort. There was no contusion or lacera- 
tion of any part of the body ; no depression 
of the skull, nor any evidences of fracture 
of the cranium. Pressure over the cervical 
region gave severe pain. The spinous pro- 
cesses of the cervical vertebrae were in line 
up to the third, but above this was a marked 
depression, while a little higher the position 
of the atlas was slightly projecting to the 
right of the median line. Manipulation 
caused so much pain that ocular examina- 
tion of the pharynx could not be made. 
Digital examination revealed a slight prom- 
inence of the second vertebral body. 

Diagnosis. — Dislocation of the axis from 
the atlas ; probable fracture of odontoid. 

During the night he slept at intervals, but 
roused at the slightest noise. There was no 
pain, except upon the movement of the head. 

In the morning he took nourishment, and 
complained of no suffering. He ate a light 
breakfast, and was anxious to go to his bus- 
iness. Three hours later he began to grow 
drowsy, and in two hours became semi- 
unconscious, but could still be roused. He 
answered questions intelligently, but closed 
his eyes as soon as he had ceased speaking. 
The tongue was protruded straight from the 
mouth, and with difficulty ; the pupils re- 
sponded to light ; the right eye was a little 
more responsive than the left. There was 
no paralysis, except of the bladder, the 
urine not having been passed since the acci- 



52 



Communications. 



Vol. Ixvi 



dent. The catheter secured eight ounces of 
apparently normal urine. Pulse was 80, 
full ; respiration 16, deep but not snoring. 

Twenty hours after the injury the pulse 
was 48 ; respiration 12, somewhat stertorous, 
not puffy nor blowing. Could be roused 
only with effort. Answered unintelligibly ; 
occasionally, however, an articular word 
escaped. He constantly pulled at the bed- 
clothes. The urine dribbled. Pupils were 
nearly the same size, but the left responded 
more readily to the light. At the junction 
of the forehead with the hair, for an inch 
and a half to the left of the media line, ap- 
parently the point where the head came in 
contact with the ground in the fall, the scalp 
was oedematous and there was a slight de- 
pression. Pressure upon several points in 
the same region gave similar pitting. No 
evidence of fracture. 

No injury could be discovered in any por- 
tion of the body save the neck. 

There was no paralysis of any portion of 
the body, but there was slight impairment 
of motion of the right arm and leg. The 
head could be moved with little more free- 
dom toward the left, but a slight force 
caused the patient to cry out and to steady 
his head with his left hand. There was 
rather less deformity than at first at the 
back of the neck ; the thyroid was not so 
prominent. Liquid food was taken without 
difficulty. He passed a restless night, con- 
stantly pulling at the bedclothes, tossing 
about on his couch, and muttering in deli- 
rium. 

Forty hours after the injury it was noticed 
that he moved the right arm and leg less 
frequently although both members could 
still be brought into use by a special effort of 
will. Pupils as the day before ; respiration 
also ; pulse 60. The patient responded to 
loud shouting, but could give no intelligible 
answers, although frequent attempts at utter- 
ance were made. The urine dribbled con- 
stantly. 

Seventy-two hours after the accident the 
pulse was 100 ; respiration 20. Increased 
loss of power, but members still capable of 
being moved. 

Eighty-four hours after the injury the 
pulse was 130, feeble ; respiration 24. De- 
lirium less violent. Patient remained quiet, 
except when partially awakened. When 
roused by any cause the left hand still 
pulled the bedclothes. The right arm and 
leg were still capable of being moved 
slightly, but the muscular power was weak- 
ened. Unconsciousness increased with total 
inability to speak. Bowels not moved since \ 



the accident. Pupils normal in size, still 
contracting under the influence of light. 
Liquid nourishment has been swallowed up 
to this time, but was now refused. Died 
quietly ninety-eight hours after the injury. 

Post-mortem. — Examination of the neck 
alone was permitted. The posterior cervical 
muscles were filled with extravasated blood 
from the occiput to the fourth vertebra. 
The spinous prominence of the atlas lay to 
the right of that of the axis and on a plane 
posterior to it, causing the axis to appear as 
though it had been pushed forward. In 
reality, however, its position in relation to 
the third vertebra was normal — the atlas be- 
ing the dislocated bone. The left inferior 
articular process lay behind the articular 
process of the axis, while the right inferior 
articular process of the atlas lay anteriorly. 
This displacement was permitted by a frac- 
ture of the odontoid process of the axis. One 
fracture extended directly across its base, 
while the other had broken off a small por- 
tion of the anterior surface — the line of the 
fracture being almost at right angles to the 
first. The odontoid process, however, was 
still held in position by the transverse odon- 
toid ligature, which was unruptured. As 
noticed during life, the atlas could not be 
rotated to the right, while it could be turned 
to the left. Strong extension made upon 
the atlas permitted it wuth difiiculty to be 
brought into position. 

Fracture of the Third, Fourth, and Fifth 
Lamina} ; Death. — W. P., aged forty years, 
fell from a scaffolding, a distance of twenty 
feet, striking the top of his head on a curb, 
and alighting as nearly as possible with the 
axis of his body in a straight line. When 
seen half an hour later he was suffering 
from shock. His pulse was 80, and his 
respiration feeble. He was perfectly con- 
scious but indifferent to surroundings. There 
was a large, lacerated wound of the scalp 
four inches in length transversely across the 
forehead. In the region of the third and 
fourth vertebrae there was marked displace- 
ment forward of the third with prominence 
backward of the fourth dorsal spine. There 
was total paralysis of both motion and sen- 
sation, and of all parts of the body below 
the portion supplied by the corresponding 
nerves. Neither urine nor faeces had been 
passed since the accident. There was no 
priapism. Extension and counter-extension 
had no effect on the deformity. 

The patient rallied for two hours, the 
pulse reaching 110 and the temperature 
100°. He complained a great deal of pain 
in the back of his neck and shoulders. Soon 



January 9, 1892. ' Communications. 



53 



afterward tlie respiration became more hur- 
ried, the heart's action much more feeble, 
and although perfectly conscious for one or 
two hours, he soon sank into a state of 
drowsiness, and died ten hours later. 

At the autopsy there was found a fracture 
of the body of the fourth dorsal, with frac- 
ture of the lamin?e of the third, fourth, and 
fifth. The third was greatly displaced for- 
ward, carrying with it a fragment of the 
fourth. The cord was entirely torn across 
at the junction of the third with the fourth, 
and was pulj^ified for half an inch and com- 
pressed l3y the fragments of the other 
laminae. 

Laminsectomy would haye relieyed pres- 
sure, but would not haye restored the 
crushed and torn cord. 



SUPRA-VAGINAL HYSTERECTOMY.- 



BY J. M. BALDY, M. D., 

PROFESSOR OF GYNAECOLOGY IN THE PHILADELPHIA 
POLYCLINIC ; SURGEON TO GYNECEAN HOSPITAL ; 
GYN.^:C0L0GIST TO ST. AGNES' HOSPITAL. 



It is not the object of this paper to discuss 
the different methods of surgical treatment 
for uterine tumors nor to more than inciden- 
tally touch upon their medicinal treatment. 
My personal practical experience in the sur- 
gical direction has been wholly that of 
supra-yaginal amputation, excepting in those 
cases of small uterine fibroids where it has 
been been found adyisable to remoye the ap- 
pendages only. In this connection I may 
say that where the opportunity presents to 
choose between the remoyal of the append- 
ages and the enlarged uterus itself, I always 
fayor the remoyal of the diseased uterus, 
along with the tubes and oyaries. The one 
and only point which comes into considera- 
tion in this decision is whether or not the 
uterus is large enough to be deliyered 
through the abdominal incision. If it can 
be deliyered, the hysterectomy is always per- 
formed. To my mind one of the great ad- 
vantages gained in hysterectomy, by the 
extra-peritoneal method,^oyer oophorectomy, 
is that no stump or raw surface is left in the 
peritoneal ca^dty to become the seat of sup- 
puration, or to whose freshened surface loops 
of intestine can become adherent. In un- 
complicated cases the operation amounts to 
little more than an exploratory incision, 

*Read. before the Philadelphia County Medical 
Society, December 9th, 1891. 



and in my opinion is as safe as an ovario- 
tomy. 

I have operated fifteen times for large ute- 
rine tumors. In fourteen cases the uterus was 
removed, but in the remaining case the oper- 
ation was ended as an exploration. Of the 
fourteen finished operations, two died. 

The patient whose tumor was not removed 
was a white woman about thirty-five years 
of age. The growth had existed for more 
than ten years. AYhen she Avas first seen 
she was in bed, where she had been for some 
weeks, with an attack of abdominal pain. 
For months she had only been able to be 
about at odd times, and considered her life 
a burden. An operation had been proposed 
to her a long time before, and its dangers 
brought vividly before her eyes. She had 
continued to suffer from pain and haemor- 
rhage, until, in spite of her former fears, she 
was, at the time I saw her, determined to 
have the operation performed at all hazards. 
In spite of her long suffering she was still a 
strong, hearty-looking woman. The abdo- 
men was opened at the Gynecean Hospital 
before a number of physicians, and the 
tumor found to extend above the pelvic 
brim. The intestines were adherent over it 
at various points, and had to be torn loose 
in order that a careful exploration could be 
made. The growth was found to be in the 
broad ligament,and was consequently immov- 
able. The only adhesions which existed 
were the intestinal ones, which had been 
torn through. The removal of the tumor 
meant a complete enucleation of a solid 
growth, with all the chances of death from 
hsemorrhage which such procedure entails. 
It was decided wise to end the operation, 
explain the condition to the woman, and let 
her decide whether or not she desired to 
risk its removal at some subsequent time, or 
preferred a trial at electro-puncture. The 
result was a complete symptomatic cure. It 
is now some five or six months since the 
operation and the woman declares she has 
never been so Avell in her life ; she attends 
to all her duties, goes to dances, and in other 
ways leads an active life. She declares that 
the tumor is rapidly decreasing in size, and 
is most confident that it will disappear alto- 
gether. She looked at me most sceptically 
when I told her it would not go away, and 
that some day all her old symptoms would 
come back. 

The last time I saw her — a month ago — I 
was considerably staggered by the fact that 
there was an undoubted decrease in the size 
of the enlargement. It is barely possible 
that it might eventually turn out to be 



54 



Communications. 



Vol. Ixvi 



another example of a solid tumor becoming 
absorbed after an exploration ; several such 
cases have been reported by Tait and others. 

One of the points of greatest interest to 
me in this case is the fact that her relief is 
not dissimilar to what is claimed for the elec- 
trical treatment. Had she gone to Dr. 
Massey for that treatment, as I advised her 
to do, and which she would have done had 
she not gotten well so rapidly, electricity 
would have obtained the credit for the cure. 
As it is, the lesson taught should not be lost. 
Is it not possible that the great relief ap- 
parently obtained by the electrical treatment 
is at times a mere coincidence ? Or would 
not any profound impression bring about 
a similar result in at least some of these 
cases ? 

The two cases which died were both very 
bad subjects for operation, and their deaths 
can in no way be used as an argument against 
the operation. The true deduction to be 
drawn from the result in these two cases is 
that the operation should not be left as a 
last resort, as is advocated by Keith and the 
electricians, but that it should be undertaken 
early, and while the tumor and patient are 
both in a good condition of health. It is the 
same old battle which had to be waged so 
long and so vigorously in the case of ovarian 
cysts, and the end will be just as surely the 
same — that is, removal before the woman's 
health is broken down, and before the tumor 
becomes unhealthy and adherent. 

The first death occurred in a colored wo- 
man, about 35 years of age. The tumor was 
extremely irregular, and extended up to the 
ensiform cartilage. The patient was in the 
last stages of emaciation, and could only 
walk with the greatest difficulty. It was a 
serious question in the minds of some of my 
colleagues, who examined her, whether the 
disease was not splenic or a malignant omen- 
tum. I was rather inclined to the latter 
opinion myself, and went to the operating 
table prepared to meet any condition or com- 
plication whatever. The woman, her hus- 
band, and her doctor were all told that her 
chances for recovery without the operation 
were nil; with the operation that they were 
little better, although there were some and 
the only chance. They all agreed upon 
having the operation, and it was performed 
at the Polyclinic Hospital in the presence of 
my class. The omentum was adherent over 
the upper part of the tumor, which proved 
to be a nodular uterine fibroid. The omen- 
tal vessels, which were as large as the radial, 
were tied and cut away, and the tumor 
delivered. The appendanges were diseased, 



and on one side the tube was distended with 
caseous matter. A good pedicle was secured, 
and the woman was in her bed within the 
hour. For five and a half days there was 
but a single bad symptom — a pulse between 
forty and fifty beats to the minute. The 
bowels were opening daily of their own 
accord, the temperature was normal, the 
appetite was good, and solid food was being 
taken with a relish. The abdomen was flat, 
and there was a minimum amount of pain. 
She was so well that her doctor was notified 
that she was safe. At the end of the fifth 
day she began to develop bad symptoms ; 
the abdomen gradually distended, the pulse 
became rapid and hard, the temperature 
slightly elevated, the bowels obstinately con- 
stipated, food was refused, and finally vom- 
iting set in, and she died at the end of three 
and a half days from septic peritonitis. 

How it was contracted is still a mystery 
to me, as there was no drainage-tube used, 
and the dressings had not been touched since 
the day of the operation. The stump was 
perfectly dry and sweet. 

The second case was that of a white 
woman, thirty- two j^ears old. Three years 
ago she had consulted me, and refused 
operation, preferring electrical treatment. 
Off" and on during this period she was under 
the care of Dr. Massey, and toward the end 
he resorted to electro-puncture through the 
vaginal vault. She stood this treatment 
fairly well for a few times, but finally sup- 
puration occurred and a sinus track opened 
on the outside of the left labia. Pus dis- 
charged freely from both the vagina and the 
outside sinus. When Dr. Massey asked me 
to see her with the view to an operation, she 
was bed-fast and could barely move; she 
was profoundly septic, and too tender to 
handle. A finger in the vagina disclosed a 
fluctuating nodule, apparently of the fibroid, 
in the posterior cul-de-sac. This, taken in 
conjunction with the discharge of pus, made 
a pretty clear diagnosis of suppurating 
fibroid tumor following electro-puncture. I 
gave as my opinion that the only chance the 
woman had for her life was to get rid of the 
suppurating mass. Everybody concerned 
was willing and anxious that she should be 
given the chance, so 1 admitted her to my 
wards at St. Agnes's Hospital and per- 
formed the operation. The intestines and 
omentum were found adherent to the top of 
the tumor; the tumor was adherent in 
every direction to the pelvic walls; both 
ovaries were found posterior to the uterus, 
and both formed cysts as large as a goose- 
egg and an orange respectively ; the tubes 



January 9, 1892. Society 



Reports. 



55 



were both diseased. The appendages were 
closely adherent, and only freed with diffi- 
culty. It Avas found that the fibroid was 
not suppurating, but that one of the ovarian 
cysts was. The puncture-needle in one or 
more of the treatments had entered this 
cjst, which was almost directly in the 
median line, and was the " fluctuating 
nodule" which was detected at the first 
examination. The external sinus opened 
into this cyst, and when the tumor was re- 
moved it left the open mouth of the sinus 
behind, at the same time deluging the whole 
pelvis with the dark, virulent cyst contents. 
A clean removal of the uterus and both ap- 
pendages was secured ; the pelvis was flushed 
out most carefully and thoroughly, and a 
drainage-tube was placed at the opening of 
the sinus track. In spite of all precautions, 
the w^hole pelvis suppurated, and the woman 
died of septicaemia on the sixth day. 

Certain it is that neither of these deaths 
ought to weigh against the operation of 
hysterectomy in cases where the conditions 
are fairly favorable. If cases are ever to be 
considered last-resort ones, these come in 
that class, and had I been operating for 
statistics rather than for the good of the 
women, nothing would have induced me to 
touch either of them. 

As I have said, twelve cases recovered, 
and went home well women. With one or 
two exceptions, they were all complicated 
cases — short, thick pedicles, or pedicles 
which had to be manufactured ; diseased 
tubes and ovaries ; adhesions. One case 
had a nodule as large as the fist protruding 
into the vagina from the cervix. This mass 
had been sloughing for weeks, and the 
woman was deeply septic. The operation, 
which was performed at the Gynecean Hos- 
pital, was done in two stages. With knife 
and scissors the sloughing tumor was re- 
moved from the vagina. The instruments 
were quickly changed, and a supra-vaginal 
amputation finished the operation. So septic 
was the woman, that when the stitches were 
removed on the eighth day the whole line of 
the incision gave way and the intestines pro- 
truded in a mass. They remained out for 
about two hours before I could be found to 
replace them. Fortunately, my assistant, 
Dr. A. C. Wood, reached the hospital earlier 
than myself, went immediately to work, and 
was just replacing the protruding mass as I 
walked into the operating-room. In spite 
of this accident she made a good recovery, 
and is to-day well and at her usual occupa- 
tion. Two of the twelve patients who re- 
covered from the operation are dead. The 



other ten, as far as I know, are alive and in 
better health than they have been for 
years. The two deaths were due, in one 
case, to a subsequent operation for an 
ovarian cyst; in the other, presumably to 
heart disease. About six weeks or two 
months after her return home, while in ap- 
parent perfect health, she was suddenly 
seized with syncope, and was dead within 
half an hour. 



Society Reports. 



PHILADELPHIA COUNTY MEDICAL SO- 
CIETY. 



Stated Meeting, December gth, i8gj. 



Dr. De Forrest Willard read a paper on 
Fractures and Injuries of the Spine 
IN THE Cervical Region, etc. (See p. 49.) 

Dr. J. W. Baldy read a paper on Supra- 
Vaginal Hysterectomy. (See p. 53.) 



DISCUSSION. 

Dr. G. Betton Massey : — Dr. Baldy is 
to be commended for going into the subse- 
quent history of his cases — a thing that is not 
often done. I must, however, take issue with 
him in regard to the case which I referred 
to him. I feel perfectly confident that in 
each puncture the needle went into solid tis- 
sue, and not into a cyst. The position of 
the nodule was that of a retroflexed uterus, 
a mass clearly presenting in the posterior 
vaginal vault. Another reason against the 
view of Dr. Baldy is that at no time was 
there any reaction from the puncture. An 
abscess formed, opening on the inner side of 
the thigh, but I certainly saw no septic con- 
dition. The temperature was not above 
99.5°, and my idea of sepsis is connected 
with a higher temperature than that. This 
was her condition up to the time of operation, 
and in fact the woman felt so well that I had 
great difficulty in prevailing on her to have 
the operation performed. I think that, pos- 
sibly, if the operation had been limited to a 
vaginal procedure, with the object of evacu- 
ating the pus, the result might have been 
different. 

I think that Dr. Baldy should also have 
mentioned that three years ago, when the 
woman came under his observation, she was 
exceedingly tender on both sides in the re- 



56 



Society 



Repofts. 



Vol. Ixvi 



gion of these diseased appendages. This 
makes me think that the diseased appendages 
had been present for a long time, acting as 
a hindrance to the electrical work. After 
this condition was revealed by section the 
better plan would have been to remove the 
appendages and allow the healthy fibroid to 
remain. 

I also want to take exception to the sug- 
gestion that the results of electricit}^ are sim- 
ply coincidences. Coincidences are very 
fortunate adjuvants in most of our work, 
but they are a mighty poor thing to depend 
upon. I do not think that the electrical 
workers throughout the world who have 
treated these tumors, could have gotten their 
results simply through coincidences. 

It might also be said that the result ob- 
tained in a case which I saw yesterday was 
a coincidence. This was a dispensary pa- 
tient that had been treated by abdominal 
electro-puncture as well as by vaginal elec- 
tro-puncture and intra-uterine applications. 
Up to the time of the use of abdominal 
puncture, in which three needles were sim- 
ultaneously employed, the progress was slow. 
She was quite lame from pressure on the 
crural nerve, and possibly from diseased ap- 
pendages. ]n this case operation was re- 
cently urged by Dr. Baldy. As the result 
of these punctures, and the use of a current 
of 100 to 200 milliamperes, she is now so 
comfortable that she has not time to come to 
the dispensary for further treatment, the 
tumor being very materially reduced in size. 
After being an object of charity for years, 
she is now earning a living at general house- 
work within a half square of this hall. 

Dr. Charles P. Noble : — My own ex- 
perience with abdominal hysterectomy has 
not been very large, for the reason that 
most of the fibroids that I have seen have 
not especially troubled their possessors. The 
majority required only medical treatment. 
Probably not more than ten per cent, were 
especially troublesome, and many of the 
women did not know that they had any 
tumor. On the other hand, as we all know, 
fibroids can give rise to dangerous symptoms 
either from haemorrhage or pressure. 

In my work I have taken a view opposite 
to that of Dr. Baldy, particularly when the 
fibroid is from medium to small. If the symp- 
toms demanded operation, I have felt that I 
was doing the patient the best service by re- 
moving the appendages and not disturbing 
the tumor. None of these cases have died, 
and the results have been all that could be 
desired. An objection to hysterectomy by 
the extra-peritoneal method is, that a weak 



spot is left in the abdominal wall which is 
liable to become the seat of hernia. This is 
one reason why I prefer removal of the ap- 
pendages w^here it can be done. Where the 
appendages are diseased, particularly if pus 
is present and discharged into the pelvic 
cavity, this would influence me to remove 
the fibroid, particularly if it just about filled 
the pelvis. If this were not done, I should 
anticipate death from sepsis. It is practi- 
cally impossible to wash out the pelvis if the 
tumor about fills it, and with the tumor 
present it is impossible to secure drainage. 

I quite agree with those who urge early 
operations w^hen the tumors are giving rise 
to trouble. I have witnessed some fifteen 
hysterectomies, although I have done but 
tw'O myself. All of these cases have re- 
covered. Where the operation is not com- 
plicated by adhesions, and w'herethe patient 
is not broken down, I quite agree that the 
risk of the operation should not be greater 
than that of ovariotomy. 

Dr. B. F. Baer: — I congratulate Dr. 
Baldy upon his success, and I believe that 
in the main I agree w'ith him as to his advice 
in regard to operation. Where the appen- 
dages can be thoroughly removed, and the 
tumor is small, I should prefer to remove 
them, but in some cases they are so spread 
out that thorough removal is not possible. 
In such cases I prefer hysterectomy. The 
result in early hysterectomy is very good, 
almost as good as in ovariotomy, and I have 
become an advocate of early hysterectomy 
in the cases requiring operation. In my ex- 
perience, fibroid tumors, as a rule, do give 
rise to trouble. The fact that the patient 
submits to an examination, and will submit 
to treatment by electricity, by puncture, and 
other methods of treatment more or less 
painful, and even to hysterectomy, shows that 
the disease does give rise to trouble. I can- 
not understand why it is that men of large 
experience say that fibroids are not attended 
with symptoms. It is seldom that fibroids 
actually kill, but often the patient would 
prefer death to a continuance of the sufier- 
ing. When, therefore, the tumor is giving 
rise to symptoms, and is of such a nature 
that its removal is not very dangerous to life, 
and the appendages are readily entirely re- 
movable, I prefer hysterectomy. 

Dr. Baldy did not discuss methods, and 
therefore I shall not take up that subject, 
except to say that I believe the pedicle 
should be treated intra-peritoneally when- 
ever practicable — i. e., when it is small. This 
certainly simplifies the operation, renders 
the after-treatment easier, and makes the 



January 9, 1892. Selected Formulce. 



57 



condition of the patient after recovery more 
satisfactory. The patient recovers as well, 
if not better, when the pedicle is dropped. 
In the case that died at the Polyclinic Hos- 
pital, I have thought the result might have 
been different had the pedicle been dropped. 
My impression is that the woman died of 
tympanites more than anything else, and, as 
is well known, the extra-peritoneal method 
of treating the pedicle is very apt to be fol- 
lowed by tympanites and obstruction of the 
bowel from traction on the rectum. 

In regard to Dr. Massey's case, I can 
scarcely agree that the appendages could 
have been removed and the uterus left. One 
of the tubes was quite diseased and spread 
over the tumor. If any operation was indi- 
cated hysterectomy was the one, and the 
only portion of the technique that I would 
dissent from is the manner in which the 
pedicle was treated. 

Dr. Baldy : — In regard to the treatment 
of the pedicle I shall only say that I prefer 
to treat it outside, and my experience has 
been such that I shall always employ the 
extra-peritoneal method. The advantages, 
both theoretical and practical, are in favor 
of this plan. 

In regard to Dr, Massey's case, I can only 
theorize as to the point of the puncture. I 
think myself that the majority of the punc- 
tures extend into the fibroid, but I know 
that some of them had been into the cyst, 
thus infecting it. The cyst was densely ad- 
herent at the point of puncture. I do not 
think that a fibroid will always show where 
a puncture has been made. 

I have not seen much tympanitis after 
hysterectomy. Those cases that get well do 
not have distention. Where there is septic 
peritonitis there is always obstruction. In 
both of the fatal cases that I have reported 
there was well-marked septic peritonitis. 
Neither can I agree in regard to the liability 
to hernia after this operation. I have seen 
only one hernia after hysterectomy, and that 
occurred at the seat of the drainage-tube an 
inch above the pedicle. Although I see 
many cases after abdominal section coming 
back complaining, I have not seen one case 
of hysterectomy with post-operative trouble. 

Many operators prefer oophrectomy, and 
always do it when it can be done. I prefer 
hysterectomy, and give it the preference. In 
some cases you cannot remove the ovaries, 
and in others you may not be able to find 
the ovaries. In the case of exploratory 
operation reported, I found one tube which 
was distended with a bloody fluid, but I 



could not find the corresponding ovary or 
the ovary and tube of the opposite side. 

Sometimes fibroids do not give rise to 
symptoms. One case operated on had very 
few symptoms. The girl had been told that 
she had a tumor, and came determined to 
have an operation, feeling that she would die 
if the tumor were not removed. The tumor 
was large. There was little haemorrhage or 
pain, but there was one point which would 
in the opinion of many justify operation, 
and that was that the patient was only 
twenty-five years of age and the tumor was 
growing rapidly. The vast majority of fib- 
roids I have seen have been advised to have 
nothing done. In future, with my present 
experience, I would consider such advice, in 
many of these cases, as unjustifiable. 



Selected Formula. 



SORE MOUTHS OF NURSING WOMEN. 

T>. Listerine ij. 

jpk; Glycerini fSij. 

Aquae menth. pip fS ij. 

M. Sig. Use a mouth wash two or three times a day. 

— Weekly Med. Rev. 

A LOTION FOR THE ALOPECIA FOLLOW- 
ING ACUTE DISEASES. 

The following formula is given Union 
Medicale) as a preventive of the alopecia 
which is observed during convalescence from 
grave acute diseases: 



Alcohol, 80 per cent S 2%. 

Camphorated alcohol 5 1^. 

Rum 5 1^1. 

Tinct. of cantharides 5 1%. 

Glycerin 5 1%. 

Essence of sandalwood, wintergreen 

and roses of each gtt. v. 

Muriate of pilocarpine gr. vijss. 



If the hair becomes dry, inunctions of oil 
of sweet almonds or castor oil may be made 
from time to time. — Univ. Med. Mag. 



HEADACHE. 

In many cases rebellious to all other 
medication, Pescarolo has obtained good 
results with the following mixture : 

T) Antipyrin grammes iv. 

Phenacetin " ij. 

Antifebrin gramme j. 

He supposes that the favorable action is 
due to a new body which is formed in the 
mixture. — Nouveaux Bemedes, June 8, 1891. 



COMPOUND WINE OF CREASOTE. 

Dr. Fraenkel (II Raccoglitore Medico, 'No. 
14, 1891) gives the following to tuberculous 



58 



Selected Formulce. 



Vol. Ixvi 



patients whose temperature is not high and 
in whose sputa the bacilli are not numerous : 

T> Creasote grammes xv. 

XV Tinct. gentian " xxx. 

Alcohol " cclv. 

M. Two or three tablespoonfuls a day. 



TREATMENT OF SWEATING HANDS. 



Medecine gives the fol- 



The Journal 
lowing : 

T>. Tinct. of belladonna 5j. 

Cologne water Sj. 

M. Add a little glycerin at the moment of using, and 
with the mixture rub the hands strongly. The hands should 
first be washed in soft water and thoroughly dried. 



TREATMENT OF SYPHILIS DURING PREG- 
NANCY. 

E. Besnier recommends the following 
course of treatment : 

1. Tonic medication. Good food, syrup 
of the iodide of iron, preparations of quinine. 

2. Specific medication. Give every day 
one pill, as follows : 

T>. Hydrargyri bichloridi gramme o.oio. 

Jp» Extracti opii " 0.005. 

Extracti gentianae " 0.005. 

Glycerine q. s. ut ft. massa. M. 

Sig. For one pill. 

3. At the same time prescribe iodide of 
potassium is doses of 0.50 to 1.0 gramme (7^^ 
to 15 grains). 

This treatment in continued throughout 
pregnancy, and the increase in the weight of 
the patient will testify to its efficiency. — 
Revue Medico- Chirurgicale des Maladies des 
Femmes, July 25, 1891. 



FOR BLENORRHAGIA. 

In the treatment of this disease, P. Thiery, 
{Anal, de Malades Oenito-urinaires) recom- 
mends during the first period, abortive injec- 
tions of nitrate of silver, and during the 
second period injections of iodoformated oil, 
frequent bathing, alkaline drinks, good diet, 
etc. After urination the following formula 
should be employed for injections : 

TX Iodoform, finely powdered grammes x. 

-C)y Oil sweet almonds or glycerin. " Ix. 

A disinfectant substance, such 
as eucalyptus, vanilline, etc.q. s. 
M. Sig. A syringeful of lo c.c. is to be injected, and 
the injection kept in for lo minutes. 

— La Medecine Moderne, November 19, 
1891. 



ANTIPRURITICS IN URTICARIA. 

Quinquad (Deutsche Medicinische Woch- 
enschrift, 1891 ; No. 32). 

Lotion. 

T>. Boric acid grammes xxx. 

-L^ Chloral hydrate " v. 

Distilled water " clxxx. 

For external use. 



Dusting-powder. 

T> Salicylic acid grammes v. 

-CV Zinc oxide " xv. 

Powdered starch " xxx. 

For external use. 

At the same time, alkalis are administered 
internally, and if these fail to produce an 
effect, sodium arseniate. 



VARICOSE ULCERS. 

Dr. J. Braun (Lo Sperimentale, No. 14, 
1891) speaks highly of the following salve: 

TX Zinc pxyd 5 iv. 

-I^k) Lanolin S iv. 

Ung. emmolient S jss. 

M. f. ung. Apply locally on a piece of cloth a layer 
of the thickness of a knife-blade and over this a bandage. 

Keep the patient abed until the ulcer haa 
healed. If the ulcer has an unhealthy ap- 
pearance the dressing should be removed 
three to four times daily. 

The unguentum emmoliens of the Austrian 
Pharmacopoeia is composed of white wax, 
10 grammes ; spermaceti, 20 grammes ; oil 
of sweet almonds, 80 grammes ; rose water, 
20 gramines. 

TREATMENT OF HYPERIDROSIS. 

In the Revue General de Clinique et de 
Therapeutique, the following prescription for 
sweating of the hands and feet is given. The 
application is to be made night and morn- 
ing. The part is first washed with hot 
water and immediately afterward the follow- 
ing ointment is applied : 

"P Ichthyol Sj. 

1)0 Vaselin 5 jss. 



ANTISEPTIC ADHESIVE OINTMENT. 

The following is an antiseptic adhesive 
ointment used at the hospital St. Andre : 

T), Zinci oxidi gr. ivss. 

JlV Zinci chloridi gr. xxijss. 

Gelatinae 5 v. 

Aquse 5 vijss. 

This dressing protects the surface of 
wounds and dispenses with the use of ban- 
dages after operations. It is especially of 
service for the dressing of wounds on the 
face. — Gaz.' JSehdomadaire des Sciences 
Medicales, August 16, 1891. 

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

Prof M. V. Soubbatine (II Raccoglitore, 
No. 12, 1891) employs the following in epi- 
demic cerebro-spinal meningitis : 

T>, Sodol. pur grammes 3. 

-Pa Acetanilid " 1.80. 

Sufficient for twelve pills. Three or four during 
twenty-four hours. 

Soubbatine cured one severe case and 
Kratow saw rapid recovery follow in two 
cases after the use of these pills. 



January'9, 1892. 



Editorial. 



59 



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Leading Article. 



PEROXIDE OF HYDROGEN IN THE TREAT- 
MENT OF DIPHTHERIA. 

The success which followed the use of 
peroxide of hydrogen as a solvent and anti- 
septic in the treatment of ulcers and sup- 
purating cavities soon suggested its employ- 
ment in diphtheria. When we reflect that 
this substance was discovered in 1818 and 
that it has many times been advocated by 
experienced observers, it seems strange that 
its value was not earlier appreciated. 
During the past five years, however, it has 
taken a prominent place among antiseptic 
and germicidal remedies, and from the pres- 
ent expression of medical opinion it is cer- 
tain that its usefulness will be greatly ex- 
tended. 

The evident advantage of peroxide of 
hydrogen over all other substances having 
the power of destroyiug disease-germs is its 
almost entire harmlessness and the readiness 
with which it can be employed in the various 
cavities of the body, as well as externally. 
Its efficacy being due to the potency of the 
nascent oxygen liberated when it is brought 
in contact with organic matter, it more 
thoroughly and safely reaches the substances 
we wish to destroy than any other agent of 
its class. 

While there are some expressions of doubt 
of the ability of this substance as a germi- 
cide, there is, on the other hand, no question 
that it is in this respect one of the most pow- 
erful agents known to the bacteriologist. 
When it is remembered that the medicinal 
peroxide of hydrogen should be of fifteen 
volumes strength and that but few speci- 
mens in the market are of over five, it is not 
strange that the results obtained from its 
use have not been universally satisfactory. 
Surely no more can be expected of this sub- 
stance if in too weak solution than of the 
now popular bichloride under the same cir- 
cumstance. Regarding the proof of its 
germicidal power, we would refer to the ex- 
periments of Miguel who found, after a long 
series of carefully conducted observations 



6o 



Editorial, 



Vol. Ixvi 



that only two other substances are more 
powerful germicides than this ; the two being 
the biniodide of mercury and the same salt 
of silver. He thus accords to the peroxide 
of hydrogen greater germicidal strength 
than that possessed by bichloride of mer- 
cury. These researches have been repeatedly 
confirmed, and it has even been shown that 
it is positively destructive to spores, the most 
difficult of organic matter to destroy. Gif- 
ford found that a contact of forty-five 
seconds was sufficient to kill adult anthrax 
spores. 

In the local treatment of diphtheria we 
have three primary indications : First, to dis- 
infect the discharges and thus prevent the 
absorption of septic substances ; second, to 
destroy the disease-germs ; third, to remove 
the false membrane. From the present state 
of our knowledge concerning the properties 
of peroxide of hydrogen, it seems that in it 
we possess a substance which largely, if not 
entirely, fulfils these indications. Moreover, 
when we add that it is harmless when taken 
internally, easily applicable to all varieties 
of the disease and to all ages of the patients, 
certainly no local application of which we 
are aware so fully meets our wants. 

The literature of the subject offers much 
valuable information respecting its utility 
in this grave affection. For instance. Dr. 
Bleyer says : " While the membrane is thin 
and friable, the action of this agent is 
thorough, quick and effective ; the deposit 
melts down before the contact of it like 
sugar in water, to be reproduced in a short 
time and again removed until the diseased 
tissue beneath can be plainly seen free from 
this cliaracteristic covering." Such illustra- 
tions might abundantly be given. 

What is the best method of applying this 
substance ? The answer to this question 
will be modified by many circumstances, 
such as the age and tractability of the patient, 
the location of the membranous deposit, 
etc. If the case is an adult or a child who 
will co-operate with the physician, the per- 
oxide is best applied directly to the parts 
by a cotton wad or brush, which is far more 
effectual than the spray or gargling, since it 



mechanically removes the outer and most 
toxic portions of the membrane and permits 
of immediate penetration of the peroxide to 
the deeper layers or even to the mucous 
membrane. Such applications should be 
followed by similar ones of the bichloride of 
mercury. In case of nasal complication, it 
must be applied by means of insufflation or 
injection to the affected parts. Atomizers 
can now be had specially constructed to pro- 
ject the spray to the posterior nares, and by 
the same means, or by a syringe, or eye 
dropper the peroxide can be applied through 
the anterior nares. In cases of children 
where the resistance to the use of the pro- 
bang is so violent as to render the method 
inadmissable or undesirable, the pharynx, as 
well as the nasal chambers, may be flushed 
by means of a common syringe, a current 
being projected through each nostril. Should 
the nose become stopped up it must be 
cleared by a pledget of cotton on a suitable 
instrument before the injection is attempted. 
Where the applications can be made by this 
method through the mouth, the current 
should be directed to the back of the 
tongue, to the larynx and to the posterior 
nares. Such injections are followed imme- 
diately by the formation of a frothy dis- 
charge which arises from the evolution of 
nascent oxygen by contact of the peroxide 
with the septic organic substances. In fact, 
the amount of the froth is a fair index of 
the amount of mucous membrane involved, 
and the disappearance or increase of the 
false membrane is at once indicated in the 
quantity of this discharge. 

The evidence available certainly indicates 
that hydrogen peroxide mil be found to be 
the most valuable of all substances in our 
armamentarium for the local treatment of 
diphtheria, but it is of pre-eminent impor- 
tance that only absolutely reliable prepara- 
tions should be used, which should be fresh, 
free from an excess of acid and of full 
fifteen volumes strength. It seems almost 
needless to say that the preparation should 
be kept in a cool place and that it rapidly 
deteriorates with age, and when exposed to 
the atmosphere. 



January 9, 1892. Correspondence. 61 



Correspondence. 



PHYSICIAN AND APOTHECARY— DR. WM. 
BULLEYN. 

To THE Editor of the Medical and 
Surgical Reporter: — Dr. G. Granville 
Faught in your issue of November 14th 
brings under the notice of your readers the 
name of Dr. Wm. Bulleyn, whose works — 
"The Government of Health/' 1559, 800; 
"A Regimen Against the Pleurisy," 1562, 
800; Bulleyn's Bulwark of "Defense 
Against all Sickness, Soreness aud Wounds, 
that dooe Daily Assault Mankinde," 1562, 
800 ; " A Dialogue Both Pleasant and 
Pietifull, wherein is a Goodlie Regimen, 
Against the Feuer Pestilence," 1564, 800— 
prove him to have been far in advance of 
his contemporaries. 

He was born in the early part of the 
reign of King Henry the VIII, and was 
educated at Cambridge. Afterwards he 
went on a tour through Germany and Scot- 
land where he pursued his favorite study, 
botany. 

In the year 1888 the Early English Text 
Society published a re-print of A Dialogue 
Against the Feuer Pestilence," from the 
edition of 1578 collated with the earlier 
editions of 1564 and 1575, under the 
editorship of Dr. Mark W. Bullen and A. 
H. Bullen, The work is valuable as con- 
taining the narrative of Mendasc,'' the 
original of Swift's " Splendide Mendasc," 
who describes a "fletyng Island swymming 
about the sea, by what means I knowe not, 
whether occasioned by corke, wooll, &c. ; it 
would by the winde, shifte from place to 
place. Sume said it was a shred of the 
bankes of Paradise." 

From a medical point of view the dialogues 
between the sick merchant, " Antonius " 
and the physician Maister " Tocrub," and 
the apothecary " Crispiiie " and " Toeruh,'' 
are interesting. 

Physician and apothecary on their way to 
the patient are thus described by a citizen : 
"Thether euen within this twoo howers I 
did see Maister Tocrub solmonely ridyng 
upon his mule, with a side goune, a greate 
chaine of gold about his necke, his apothi- 
carie Crispine, a neighboure's childe borne 
hereby in Barbaric, and his little lackey, 
a proper young applesquire called Pandarus, 
whiche carrieth the keye of his chamber 
with hym. These are all gone in at the 
gates to that noble Italian." 

The physician directs the attendants to 
"Drawe the fountaines, open the luket of 



the windowe, set sallowes about the bed be- 
sprinkled with vinegar and rose water. 
Take off that hot mantle ; let his head and 
shoulders be bolstered up." 

" Antonius. To what persones I praie 
you, doeth the pestilence come." " Medicus. 
Moste chiefly to theim under the place in- 
fected, then to sluttishe, beastly people, that 
keepe their houses and lodyngs uncleane, 
their meate, drinke, and clothyng moste 
noysome, their laboure and traudile im- 
moderate ; or to theim which lacke provident 
wisdome to presente the same by good diete, 
ayre, medicine, &c." ^ When there 
doth come a " sodaine alteration or change 
in the qualitie of water, ^ ^ ^ or 
when strong windes doe carrie pestilent 
fume or vapours from stinkyng places to the 
cleane partes, as bodies dead of the plaugare 
unburned. ^ ^ This is a dispersed 

pestilence by the inspiration of the ayre." 
I am Sir, Yours Truly, 
George A. Foy, F. R. C. S. L 



PROMISCUOUS SPAYING OF WOMEN. 

Editor of the Medical and Surgical 
Reporter : — In the issue of the Reporter 
for December 12th, 1891, Dr. Noble criticises 
my article on the removal of the ovaries of 
women. If the Doctor had read the article 
a little more carefully, he might have ob- 
served that I referred to " a certain class of 
ambitious young surgeons, each striving to 
count the greatest number of abdominal sec- 
tions." This, it is needless to say, does not 
include " the worthy successors and follow- 
ers of McDowell, Atlee, Sims, Wells, Keith, 
etc." 

My object in bringing the subject to the 
attention of the profession, was not to make 
baseless charges against respectable gynsecol- 
ogists, as my critic would have it, but to pre- 
vent, if possible, women from being unnec- 
essarily mutilated by *would-be operators. 
The fashionable gyniecologist would no 
doubt use more elegant terms than unsexed 
or spaying for castration of the female, but 
to the general profession these terms seem to 
be well understood and wonderfully expres- 
sive. Only a few days ago, a woman, the 
mother of four children, applied to me to 
have the ovaries removed, that she might 
have no more children. I tried to dissuade 
her from her purpose, but she seemed de- 
termined to accomplish her object, and in- 
formed me that she knew of several women 
who had gone through the operation, and 
that she expected she would have no diffi- 



62 



Book Reviews. 



Vol. Ixvi 



culty as she was prepared to pay liberally 
for it. 

This, you will observe, is another side of 
the same subject, and shows conclusively, at 
least to me, that there are certain parties 
who follow the profession of " The promis- 
cuous spaying of women." 

Very respectfully, yours, 

Wm. C. Todd. 



Book Reviews. 



THE SUPREME PASSIONS OF MAN. By Paul 
Paquin, Late Professor of Comparative Medicine, 
and Director of the Bacteriological Laboratory, 
Missouri State University ; Member of the Ameri- 
can Public Health Association; the American 
Medical Association ; Editor " Bacteriological 
World," Etc., Etc. Published by The Little Blue 
Book Company, Battle Creek, Mich., 189L 

This little book is one of a series of pub- 
lications, by the Little Blue Book Company, 
which is intended to instruct the masses re- 
garding various scientific subjects, and these 
subjects are presented in plain and simple 
language entirely suitable to the class of 
readers for whom the series is intended. 
The present volume is a freely expressed 
talk upon science, religion, morality and 
medicine, especially as they have to do with 
the supreme passions of the race. The 
author found it necessary, in accord with his 
views of the existing moral state of society, 
to reveal to the public eye the most common 
of social vices, and to his credit we will say 
that in general this has been done with con- 
siderable tact and delicacy of expression. 
The intent of the author is to prove that 
the passions of man are directly due to path- 
ological nutrition, the results of wrong meth- 
ods of living, eating and drinking, and that 
religion alone is powerless to cope with these 
passions. He shows how science and relig- 
ion together could make the world a better 
place to live in, and demonstrates logically 
how food is the primary cause of racial 
characteristics, and of the development of 
the unnatural passions. A chapter is de- 
voted to his theory of the causation of alco- 
holism, morphism, nicotism, etc., and is well 
worth the reading. While we cannot agree 
with some of ^ the views expressed, the book 
as a whole contains many plain truths, and 
is a strong argument for better and more 
careful methods of living. It may be pos- 
sible that it will do good to a certain class of 
intelligent readers, but it is certainly not a 
book to be carelessly read and condemned 
because it speaks plainly and truthfully of 
frightfully common human vices, and for 



the same reason it is possible for such 
knowledge to do some harm to pure, inno- 
cent minds. It is certainly one of the most 
vexing questions of to-day to decide just how 
the public generally should be made ac- 
quainted with such scientific truths as are 
treated of by the author of this book. We 
would heartily recommend its perusal to the 
profession as a popularly arranged contribu- 
tion to sociological literature ; and some parts 
of it will be found interesting because of 
ingenious theories respecting the growth of 
the passions. It is one of the books which 
are the outcome of the life-work of the 
author, and one may read in every page the 
effects of the writer's work in bacteriology 
and microscopic anatomy, just as the author 
of " Natural Law in the Spiritual World " 
combined in his book the results of his theo- 
logical and scientific occupations. 

A TEXT-BOOK OF PHYSIOLOGY. By M. 
Foster, M. D., LL. D., F. R. S., Professor of 
Physiology in the University of Cambridge, 
England. Fourth American from the fifth English 
edition, thoroughly revised. Philadelphia : Lea 
Brothers & Co. Octavo 1072 pages, 282 engrav- 
ings. Cloth, 54.50; Leather, $5.50. 
The appearance of another edition of 
Foster's Physiology again reminds us of the 
continued popularity of this most excellent 
work. There can be no doubt that this 
text-book not only continues to lead all 
others in the English language, but that 
this last edition is superior to its predeces- 
sors. It is evident that the author has de- 
voted a considerable amount of time and 
labor in its preparation ; nearly every page 
bearing evidences of careful revision. 
Although the work of the American Editor 
in former editions has been by the author 
largely adopted in a modified form in this 
revision, much was still left for the former 
to render the work fully adapted to the 
wants of our American students, so that the 
American edition will undoubtedly continue 
to supply the market on this side of the 
Atlantic. The work has been published in 
the characteristic creditable style of the 
Lea's, and owing to its enormous sale, is 
ofifered at an extremely low price. 

Photographs of the Bacillus La 
Grippe were presented to the Association 
Francaise pour I'Avan cement des Sciences 
by M. Tei^ier, of Lyons, and mentioned in 
Le Progres Medical of October 3d. This 
culture and inoculations with it are very 
peculiar and interesting. It produces all 
the various symptoms of la grippe and even 
pus. 



January 9, 1892. 



Periscope. 



63 



PERISCOPE. 



THERAPEUTICS. 



THE TREATMENT OF HEMOPTYSIS. 

Professor H. Nothnagel, publishes in a 
Vienna medical journal an interesting paper 
on the treatment of haemoptysis. The first 
thing, he says, is absolute rest. If the loss 
of blood is at all serious, the patient must 
not utter a sound ; if it is necessary he should 
speak, he must only whisper, or better still, 
write down everything he wants to commu- 
nicate. He must not be allowed to see 
visitors, and the sick-room must be kept at 
an even temperature. The patient must 
take nothing warm, nor anything likely to 
excite or irritate. The best food for the first 
two days is cold milk. Regular diet may 
then be resumed gradually, but all food 
which might increase the action of the heart 
must be avoided, in future. Formerly an 
opinion prevailed that the patient should be 
allowed to cough, the retention of the blood 
being supposed to be hurtful, as it was 
believed that tuberculosis was a consequence 
of haemoptysis, but this opinion is quite 
erroneous. On the contrary, one of the first 
indications is to suppress all inclination to 
cough as much as possible, for which pur- 
pose morphia is the best remedy. Should 
the haemoptysis not cease, other remedies 
must be applied. The author first mentions 
those remedies which ought to be eschewed, 
and the use of which is occasionally a phys- 
iological error. The first to be banished is 
perchloride of iron, the action of which on 
the blood is to cause it to coagulate and to 
form a thrombus. In the form of inhalation 
it would be simply useless but for the great 
danger in allowing a patient suffering from 
haemoptysis to draw a deeper breath than 
absolutely necessary for respiration. The 
liquor ferri, if administered internally, is, 
according to some, not absorbed at all, but, 
even if it be so, it would only tend to increase 
the haemoptysis. The same may be said of 
tannic acid and of alum, which contract the 
blood-vessels only when diluted to i per 
cent., and are consequently useless for haem- 
ostatic purposes as well as for inhalation. 
The author dispenses altogether with inhal- 
ation in haemoptysis. The only two haemos- 
tatic remedies he recommends as useful are 
ergotine and acetate of lead ; the first may 
be used internally and in hypodermic injec- 
tions, the latter may be given in conjunction 
with opium. Another remedy which he 



mentions, but of which he has himself no 
experience, is hydrastis canadensis. A few 
years ago hypodermic injections of atropine 
were recommended, and Prof Nothnagel has 
occasionally seen them effective. No objec- 
tion can be raised to half a teaspoonful 
of common salt when no other remedy is at 
hand. Haemorrhage from the lungs is cer- 
tainly sometimes arrested by its use, but the 
author is not quite sure if the success is joos^ 
lioG or propter hoc. Nor is he certain 
whether, as supposed by some, a reflex irri- 
tation of the pulmonary vessels takes place. 
This theory is certainly physiologically feas- 
ible, as recent experiments have shown that 
sensory excitement in some parts causes the 
blood-vessels in other parts to contract. An 
application of ice, for instance, to the abdo- 
men causes anaemia of the mucous membrane 
of the larynx. A very common remedy is 
the application of cold ; but the ice-bag is, 
according to the author, of very doubtful 
value, as it is impossible to assume that the 
cold acts directly on the bleeding surface, 
for we do not know to what depth it pene- 
trates. If the cold does act haemostatically, 
the effect must be due to irritation of the 
skin. Professor Nothnagel warns us, how- 
ever, that in some people the application of 
cold to the thorax causes cough, which is far 
more dangerous than the doubtful contrac- 
tion of the blood-vessels can be useful. An 
extreme and heroic remedy is venesection. 
It is a well-known fact that wounded soldiers 
faint from loss of blood, when the haemor- 
rhage immediately stops, and a similar ob- 
servation has been made in metrorrhagia 
and haemoptysis. — Lancet. 



HYPODERMIC INJECTIONS OF CORROSIVE 
SUBLIMATE IN DIPHTHERIA AND 
SCARLATINA. 

Dr. J. Jacontini (Morgagni, 1890) admin- 
istered by injections 1 centigramme of cor- 
rosive sublimate in eight or nine days dur- 
ing an epidemic of scarlatina. The fever 
was reduced and at the same time the mani- 
festations in the throat were modified. En- 
couraged by these results the author used 
this treatment in two cases of diphtheria 
with the satisfaction of obtaining a rapid 
attenuation of the morbid phenomena and 
followed by cure. 



MOUTHWASH FOR CARIOUS TEETH. 

A mouthwash said to prevent dental 
caries is as follows : tannin 5 grammes, tinc- 
ture of iodine and tincture of myrrh, of each 



64 



Periscope. 



Vol Ixvi 



2.5 gramme ; potassium iodide, 1 gramme ; 
rose water, 180 gramme. The mouth is 
rinsed every morning with one teaspoonful 
to a glass of warm water. — Bull, de Thera- 
peut, 1891, cxx, p. viii. 

OSMIC ACID IN GOITRE. 

Dr. S. Auerbach relates the case of a 
young woman of 25, suffering from goitre 
(the variety and dimensions not stated), in 
which he resorted to a " combined method " 
of treatment, including, a, a parenchymatous 
injection of a solution of osmic acid (1 grain 
to 2 drachms of distilled water), a syringeful 
once daily or every other day ; b, local mas- 
sage, for 15 minutes, once daily, and, c, the 
internal administration of iodide of potas- 
sium. By the end of three weeks all subjec- 
tive symptoms disappeared, while the tumor 
was found to have greatly decreased in bulk 
(was half the size compared with the period 
before the treatment). Unfortunately, the 
woman was subsequently lost from sight. — 
I etopis KhirurgitcJieskaho Obshtchestva v 
Moskve, No. 6, 1890, p. 505. 

QUININE POISONING. 

Dr. A. Erlenmeyer reports in the Central- 
hlattjur Nervenheilkunde a case of poison- 
ing with this drug which is of some interest. 
The author had previously observed aboli- 
tion of the reflexes in several patients who 
were taking large doses of quinine, but in 
the case under consideration the symptoms 
were those of an intense reflex irritability. 
The patient, aged forty-two years, had taken 
at one dose a gramme of quinine (about 
fifteen grains), and on the following day 
two grammes in divided doses. Examina- 
tion of the reflexes at this time, by tapping 
and the other tests, brought on general con- 
vulsions, with violent contractions of the 
arms and the whole body. Leaving off" the 
medication for twenty-four hours would 
cause a disappearance of the nervous excita- 
bility. 



TREATMENT OF PNEUMONIA IN DIA- 
BETICS. 

Dr. Merklen (Gazzetta degli Ospitali, 
No. 56, 1891) regards pneumonia as one of 
the most dangerous complications of diabetes. 
It appears in diabetes without any initial 
chill, pains or dyspnoea ; sometimes its pres- 
ence is marked by intense dyspnoea, due to 
congestion, which may become so severe as 
to kill the patient in one to two days — the 
fulminant diabetic pneumonia of Bouchar- 
dat. It may terminate in pulmonary ab- 



scess or gangrene, yet all cases are by no 
means fatal. The writer narrates a case 
where the sugar disappeared from the urine 
at the beginning of the disease, to reappear 
during convalescence. The same was true 
of the polyuria, hence in such cases the re- 
appearing of the polyuria and sugar in the 
urine are favorable signs. In his case there 
was no albuminuria. The writer prescribed 
caffein, 1 gramme (15 grains) a day 
hypodermatically, as a diuretic and heart 
tonic ; two or three quarts of milk daily, 
and IJ grammes (22 grains) of the sulphate 
of quinine, together with revulsion to the 



CURES FOR DRUNKENNESS. 

There appears to be some excitement in 
Illinois at present over the gold cure for 
drunkenness. Chloride of gold is said to be 
the remedy, and the Western Druggist says 
there is little new about that, for a Dr. 
Gray, of La Porte, Indiana, practices the 
following method of cure regularly. When 
he receives a patient he sets in his room a 
bottle containing a pint of good whiskey, in- 
structing the patient that he can take all he 
wishes. The doctor immediately commences 
and gives him four hypodermic injections 
each day, each containing one-tenth of a 
grain of the chloride of gold and sodium, 
and one-fortieth of a grain of nitrate of 
strychnine, and gives a mixture to be taken 
by the mouth containing the same with some 
atropine. The formula for the mixture is: 

T> Sodio-auric chloride gr. xij* 

JL)L Ammonium chloride gr. vj. 

Strychnine nitrate gr- j • 

Atropine gr. 

Fl. ext. cinchona compound 1 iij. 

Fl. ext. coca S j. 

Glycerin S j. 

Water g j. 

Mix, and take a teaspoonful every two hours when 

awake. 

He sees the patients four times a day and 
rapidly increases the gold and strychnine 
until the symptoms show that they are get- 
ting all they will bear. The first day the 
patient drinks pretty heavily of the whisky 
in his room. The second day he begins to 
lose his desire for it. By the evening of the 
third day or the morning of the fourth he is 
totally sick of it, and will not take any 
more. The treatment is carried on from 
three to six weeks. It seems to be a great 
success. We are frequently asked what 
Haines' golden specific is. A formula for 
producing a powder said to resemble this 
preparation, was contributed to the Drug- 
gists' Circular some time ago, and is as fol- 
lows : — 



January 9, 1892. 



Periscope. 



65 



Bark of bayberry root parts xvj. 

Ginger " viij. 

Capsicum " j. 

Reduce to a fine powder, and mix thoroughly. 

— Chem. and Drug. 



TREATMENT OF UREMIA. 

Prof, Tissier (Gazzetta degli Ospipitali, 
No. 25, 1891), recommends: 

1. Lavage of the stomach. 

2. Inhalations of oxygen. 

3. When the vomiting threatens to inter- 
fere with the nourishment of the patient, one 
to two drops of tincture of iodine in a spoon- 
ful of water are indicated. Creasote and 
menthol have also been successfully used. 
Lecorche and Telamon have succeeded in 
arresting the incoercible vomiting by lactic 
acid : 

T>, Acid lactic mxv-xxx. 

XV Syrup menthse pip flS j- 

Aquae destillat flS iij. 

Bouchard advises rigid intestinal antisep- 
sis. 

4. For the treatment of the cerebral and 
nervous symptoms he advises: 

For the eclampsia, chloroform by inhala- 
tion, chloral, the bromides — preferably the 
sodium bromide, bromide of potash being 
contra-indicated on account of the potash 
which it contains — paraldehyde, opium and 
its derivatives, administered with caution on 
account of the impermeability of the kid- 
neys and their tendency to accumulate. 

Rosenstein and Rossbach use the nitrate 
of sodium: 

T>. Sodii nitrat gr. xxx. 

XV Syrup cortic. aurantior fl* j. 

Aquae fig iij. 

Two to three teaspoonfuls daily. 

Labaure, Lagrave and Huchard recom- 
mend amyl nitrate, which, however, is con- 
tra-indicated when there are vascular 
changes present. 

5. In ursemic asthma tincture of gue- 
bracho or aspidospermine are to be recom- 
mended. Lecorche and Talamon regard 
venesection and morphine as the true reme- 
dies in this stage. Intra-venous injections 
of sodium salts are useful. If the heart be 
weak Avith dyspnoea, then use such heart 
tonics as caffeine, adonidine, digitalis and 
camphor. 

THE TREATMENT OF SENILE GANGRENE. 

In a recent issue of the Deutsche Medicin- 
ische Wochenschrift, Frof. Haidenhain pre- 
sents his views on this subject, which are 
based on a careful study of twenty-five cases 
of senile gangrene of the lower extremity, 
the majority of which occurred in diabetics. 
It is a well-known fact that this form of 



gangrene is ijharacterized by especial sever- 
ity, so that the author's rules for treatment 
are worthy of careful consideration. He 
advises that as long as the gangrene is con- 
fined to one or two toes we should abstain 
from surgical intervention, and wait for a 
line of demarkation to form. Local anti- 
septic measures and elevation of the limb 
are all that is required, and we are especi- 
ally warned against the detachment of the 
gangrenous portions with the scissors and 
forceps, which tends to increase the inflam- 
mation. If the gangrene spreads to the 
dorsum or sole of the foot, we should adopt 
Hutchinson's recommendation and amputate 
at the thigh, making as small skin flaps as 
possible. An extensive experience has 
shown that amputation below the knee in 
these cases is apt to be followed by gangi-ene 
of the flaps, which, if it does not lead to a 
fatal termination, renders a second opera- 
tion necessary. If high amputation is de- 
ferred until the development of fever and 
suppuration the prognosis becomes the more 
unfavorable. While it is true that a success- 
ful result has sometimes been obtained by 
amputating below the knee, the weight of 
testimony is decidedly in favor of the high 
operation. 



ANTIPYRIN IN THE TREATMENT OF 
CHOREA. 

Leroux {La Semaine Medicale, August 
12, 1891) obtained favorable results in 
forty-one of sixty cases of chorea treated 
with antipyrin. In the favorable cases, the 
disease terminated on an average at the end 
of forty-five days — the usual duration of 
chorea being sixty-six days. In nineteen 
cases, the results were not favorable, either 
because the disease proved refractory to 
antipyrine or was prolonged as post-choreic 
tic, or because the treatment was pursued 
irregularly, or was suspended on account of 
an intercurrent affection or of an intoler- 
ance of the remedy. Recurrences and re- 
lapses were, however, frequent, notwith- 
standing the continuance of the treatment. 
Forty-five grains (daily) constituted the 
minimum dose from which favorable results 
were obtained. In some instances, it was 
necessary to administer from sixty to seventy- 
five, and even ninety grains. The treat- 
ment was begun with from fifteen to thirty 
grains; for children of from eight to ten 
years, the dose was speedily increased to 
from sixty to seventy-five grains ; for chil- 
dren of from ten to twelve, to from seventy- 
five to ninety grains. Some cases yielded at 



66 



Periscope. 



Vol. Ixvi 



once to doses of from forty-fiye to sixty 
grains ; but if at the end of from eiglit to 
ten days there was no change, the dose was 
increased in accordance with the age of the 
child. If, finally, at the end of a month 
doses of from seventy-five to ninety grains 
brought about no notable amelioration, no 
more was hoped for from its administration. 
Notwithstanding the prolonged administra- 
tion of large doses of antipyrin, not a single 
grave accident occurred. 



TUBERCULIN IN LARYNGEAL PHTHISIS. 

Dr. Struebing (^Deutsche Med. Wochen., 
October 8th, 1891) records the cure of a 
case of laryngeal tuberculosis brought about 
by tuberculin. There was in the case well- 
marked evidence of pulmonary phthisis, and 
the treatment is reported to have brought 
about an improvement in the condition of 
the lungs. On examination of the larynx 
the left vocal cord was seen to be occupied 
by an ulcer of considerable size, around 
which was much swelling and redness of the 
mucous membrane. The patient was ex- 
tremely hoarse. After the first injection 
there was evidence of local reaction — swell- 
ing and injection of the laryngeal mucous 
membrane, and subjectively, increased 
hoarseness and pain in larynx, especially on 
swallowing, with slightly marked symptoms 
of stenosis. After the fourth injection no 
further reaction was observed. Kise of tem- 
perature was noted only after the first few 
injections, and then it was slight. When 
about nine had been given the ulcer appeared 
to have a cleaner look ; later, improvement 
in this direction was undoubted; the edges, 
moreover, were much less prominent, and 
presently became obliterated, the floor of the 
ulcer passing insensibly into the healthy 
tissue around. It now became gradually 
smaller, and was no longer visible after the 
forty-third injection ; this consisted of 0.1 g. 
tuberculin. The entire amount used up to 
the date of cure was 1,573 g. — Brit. Med. 
Jour. 



LOCAL ANESTHESIA PRODUCED BY IN- 
JECTION OF WATER. 

Dr. C. L. Schleich has made experiments 
of himself and his assistants, which demon- 
strate that the hypodermatic injection of 
simple sterilized water produces local anaes- 
thesia of several minutes' duration. The 
anaesthetic area becomes the seat of a white 
oedema similar to that produced by the sting 
of a mosquito, the extent of which depends 
upon the quantity of water injected. The 



technique of the procedure differs in no re- 
spect from the hypodermatic injection or 
medicated solutions; the syringe and skin 
are disinfected. The pain produced is ,no 
greater than that resulting from the injec- 
tion of cocaine, depending upon the sensi- 
tiveness of the part, and may be almost en- 
tirely prevented by spraying the parts with 
ether at the time of injection. The needle 
is inserted slowly and parallel with the 
cutaneous surface. The anaesthesia is so 
complete that incisions may be made into 
the skin without the slightest pain. — Deut. 
Medizin-Zeitung, No. 66, 1891. 



YEAST IN ENTERIC FEVER. 

M. de Bavay's paper read before the Mel- 
bourne and South Australian Branch on the 
action of yeast on the typhoid bacillus con- 
tains an account of experiments in the in- 
testinal canal of the human subject, he be- 
lieves that he has been able to obtain a set 
of conditions under which the development 
of the typhoid organism is materially inter- 
fered with, whilst such poison as it does 
secrete is so utilized by absorption from the 
alimentary canal as to confer an immunity 
against the action of the more virulent 
poison. It will be remembered that in 1887 
Dr. J. B. Buist brought forward a method 
of yeast inoculation against the action of 
small-pox ; but his experiments at the time 
were not convincing, and, though undoubt- 
edly exceedingly interesting, they were not, 
we believe, attended with any practical 
result. We shall now await with interest 
medical reports on the results of M. de 
Bavay's treatment, as only actual confirma- 
tion of the theory here put forth can enable 
any definite opinion to be pronounced. 
Those who heard the paper read at the 
meeting of the Melbourne Branch were ap- 
parently considerably impressed with a sense 
of its importance, and certainly both the 
argument and the work seem to have care- 
fully carried, out. — Brit. Med. Jour. 



MEDICINE. 



SPONTANEOUS SHEDDING OF THE NAILS 
IN DIABETIC PATIENTS. 

Prof. Auch^ Rivista Clinica e Tlierapeu- 
tica, No. 4, 1891) communicates the results 
of his studying the development of this phe- 
nomenon in diabetic patients. First a haem- 
orrhage takes place into the tissue beneath 
the nail which, according to its amount, de- 
taches the nail more or less extensively from 



January 9, 1802. Periscope. 



67 



its bed. If the haemorrhage be but slight, 
there appears a sniall and reddish film ; if 
more abundant, the nail is raised from its 
bed, remaining attached only at the extreme 
lateral borders, until a new nail forms when 
the old nail is cast off. The writer is in- 
clined to regard the spontaneous hsemorrhage 
as due to lesions of the peripheral nerves. 
His conclusions are as follows : 

1. Diabetes mellitus, like tabes dorsalis, 
hysteria and various other affections, may, 
and often does, cause spontaneous shedding 
of the nails of the hands and more frequently 
those of the feet. 

2. Shedding may take place in two man- 
ners. In certain cases the hsemorrhage and 
detachment occur without any preceding 
symptoms or disorder, when the diagnosis 
between syphilis and locomotor ataxia would 
be without the aid of concomitant symptoms, 
extremely difficult. In other cases subun- 
gual hsemorrhage may precede detachment. 
In such cases, the mechanism is similar to 
that observed in certain tabic patients. 

3. These hsemorrhages are not only due 
to changes in the vessel walls, but also, in 
some cases, to lesions of the nerves found in 
the fingers. 

MENIERE'S VERTIGO AND THE SEMICIR- 
CULAR CANALS. 
The experiments of Flourens, which 
seemed to attribute to the semicircular 
canals the role of maintaining the equilib- 
rium of the body, have been controverted 
by others to such an extent as to make it ap- 
pear doubtful whether that part of the laby- 
rinth is the seat of the lesion which deter- 
mines the so-called vertigo of Meniere. The 
peculiar character of the vomiting, the fact 
that the latter symptom may occur suddenly 
without nausea, after irritation of the mem- 
brana tympani, the intimate connections be- 
tween the pneumogastric and the auditory 
nerve at their origin, renders it more prob- 
able that the vertigo and cardiac symptoms 
are due to a reflex action in the pneumogas- 
tric dependent upon a lesion in some portion 
of the auditory nerve. The term Meniere's 
disease serves more frequently to mark igno- 
rance of the lesion which occasions a series 
of symptoms often analogous but which are 
under the influence of very different causes. 
— Sir Wm. B. Dalby, Brit. Med. Journal, 
and A7inales des Maladies de V Oreille, etc., 
vol. xvii. 

Koch is Still at Work on Tuberculin, and 
hopes to make it gradually less and less 
deadly. 



EXAMINATION OF THE EYES OF THE 
INSANE. 

M. Koget (of Lyons) states that there ex- 
ists in the greater part of the general par- 
alytic a characteristic rigidity of the pupil. 
Besides excavation of the papilla, quite fre- 
quent in the normal state, should be re- 
garded as the rule in those hereditarily pre- 
disposed, and in the insane who exhibit evi- 
dences of suicide. Finally, idiots and im- 
beciles, in respect to visual function, may be 
classed in two categories : The hypermet- 
ropic idiots are those whose infirmity dates 
back to uterine life; on the contrary, 
emmetropic and myopic idiots have become 
demented since infancy. 



ARTIFICIAL NEURASTHENIA. 

Dr. Von Pelizarva {Deutsche Med. WocJi.) 
describes a condition which he has observed 
to come on in a patient undergoing the 
water treatment at mineral springs and to 
which he has applied the name of artificial 
neurasthenia. This condition has frequently 
been described as bath or spring fever, but 
the author of the present article says that it 
is undoubtedly a form of nervous distur- 
bance resulting from the indiscriminate use 
of the bath and drinking of the mineral 
waters. 

It is well known that there is a great dif- 
ference in individual ability to react from 
certain shocks. At one time reaction from 
a cold bath would be j^rompt, at another 
there will be distinct loss of control of the 
will, shrinking and so forth, followed by de- 
pression and weakness. When such results 
obtain and the baths are persisted in the 
process will undoubtedly cause lessening of 
the resisting power of the nervous system. 
When it is remembered how great is the 
number of people ordered to the baths by 
physicians and how many go on their own 
account and take a regular course of treat- 
ment, in spite of the discomfort it may 
cause, it is not to be wondered at that pa- 
tients return w^ith neurasthenia or an ex- 
haustive neurosis. The condition is soon 
established and it is for this reason that the 
author urges upon medical advisers sending 
patients to the springs, and also upon the 
physicians attending there, greater care in 
the selection of cases destined to undergo 
regular treatment. Due to the lack of the 
necessary foresight in this regard, Carlsbad, 
and Kissengen are prominent sites for the 
promotion of this form of nervous artificial 
neurasthenia. 



68 



Periscope. 



Vol. Ixvi 



SYPHILITIC DISEASES OF THE SPINAL 
COLUMN. 

Dr. Jasinski {Archiv. fur Derm, und 
Syphilis, No. 3, 1891) maintains (1) that 
syphilis of the spinal column occurs under 
the forms of periostitis, ostitis gummosa, 
caries, exostosis, and necrosis ; and (2) that 
it is a relatively very rare affection when 
diagnosis is established beyond a doubt. 

A number of personal cases are reported, 
one of perispondylitis syphilitica; one of 
gummous inflammation of the periosteum 
and bodies of the cervical vertebrae, which 
was cured by immobilization, with a plaster- 
of-Paris dressing, and inunctions combined 
with large doses of iodide. 

Several instances of spinal affection in 
children are given and the literature of the 
subject is reviewed at some length. 



THE ORIGIN OF EFFUSIONS. 

Dr. G. Pisenti {Rlforma Medica, June 
12th, 1891) describes an experiment which 
serves to explain several points as to the 
origin of effusions. The method is simple, 
and one which can be easily demonstrated 
in the course of a lecture on pathology. The 
only preparation necessary is the following : 
A rabbit or guinea-pig is fixed in the reten- 
tion apparatus, amesthesia being produced 
either by ether or chloroform. An incision 
is then made along the linea alba about 4 
inches long, so as fully to expose the abdom- 
inal cavity. The intestines are then raised 
and turned over to the left, thus exposing 
the portal vein, into which a cannula is 
tied. This cannula is next placed in com- 
munication with a reservoir containing 
either pure defibrinated blood, a mixture of 
blood and saline solution, or simply saline 
solutions (0.75 per cent.) The liquor should 
be kept warm, and the pressure measured 
by means of a manometer. The costal arch 
is then raised so as to expose the upper sur- 
face of the liver, and the artificial circula- 
tion is commenced under a pressure of about 
2 mm. of mercury. In a few moments pale 
areas appear on the surface of the liver, 
which continue to increase as long as the 
circulation is maintained. If pressure be 
then raised a curious phenomenon is ob- 
served : numerous small drops of liquid ex- 
ude through Glisson's capsule, and after a 
time run together, so that the surface of the 
liver becomes bathed in liquid. The rapidity 
of the exudation depends upon the pressure 
at which the artificial circulation is main- 
tained. (1) There has thus been pro- 
duced a true oedema from stasis, for supply- 



ing more liquid than can be removed by the 
efierent vessels, all the effects of a block in 
the circulation are reproduced, this effect in- 
creasing with any increase in pressure. (2) 
The same method can be used to demon- 
strate the production of exudation due to 
hydrsemic plethora ; by introducing simple 
saline solution all the effects of a hypo-albu- 
minous condition of the blood can be ob- 
tained. In this case the effect on a single 
organ, the liver, will be similar to that pro- 
duced on the entire body by the intravenous 
injection of large quantities of sahne solu- 
tion. It serves well to explain the origin of 
the acites so often seen associated with a 
watery condition of the blood. (3) It is 
well known that some tissues are more prone 
to oedema than others, and this is also illus- 
trated by the above experiment, for of all 
organs that might be used the liver is that 
in which the phenomena can be best seen. 
It would appear, then, that the walls of its 
vessels are less resistant than those of other 
organs to the passage of liquids. (4) 
Lastly, from the rapidity with which exuda- 
1 tion commences, it may be concluded that 
this can happen without any alteration of 
the vessel walls themselves, and this in op- 
position to the view held by some that exu- 
dation cannot take place without initial vas- 
cular lesions. To summarize, this experi- 
ment of Dr. Pisenti demonstrates (a) that 
increase of intravascular pressure plays an 
active part in the production of exudations 
(exudation of stasis) ; (h) that exudation 
may arise from alteration in the consistence 
of the blood (exudation from hydrsemia) ; 
(c) that the histological constitution of the 
vascular walls varies from tissue to tissue, 
and from organ to organ ; (d) that exuda- 
tion may take place independently of any 
alteration in the walls of the vessels. — 
Brit. Med. Jour. 



GOITRE— ITS PATHOLOGY, DIAGNOSIS 
AND TREATMENT. 

Berry (British Medical Journal, June 13, 
20 and 27, 1891) has made an extremely 
clear and valuable contribution to the sub- 
ject of goitre. 

He makes five varieties : (1) parenchy- 
matous, (2) cystic, (3) fibro-adenomatous, 
(4) malignant, and (5) exophthalmic. All 
these varieties, except the last, which stands 
alone, clinically and structurally, run very 
much into each other, so that mixed forms 
are common. 

Prom an extensive study of the probable 
causes of goitre, Berry concludes that its co- 



January 9, 1892. 



Periscope. 



69 



incidence with limestone and calcareous 
sandstone districts everywhere in England 
is so marked that its appearance as an 
endemic disease in non-calcareous regions is 
doubtful. All attempts to produce goitre 
artificially have failed, from the experiments 
of St. Lager to those of the present day. 
Animals drinking solutions of the different 
forms of salts found in water from these 
regions, have never shown any sign of 
goitre, although goitre is common in lower 
animals in goitrous districts. 

Yet the fact that goitre can be produced 
by water has been proved accidentally from 
human experimentation. For example, in a 
regiment of young soldiers, quartered in a 
goitrous village, there developed, in a large 
proportion of the men, goitres in a few 
months or even weeks. Again, a town has 
has received a new water supply, and 
shortly afterward goitre has broken out in a 
large number of the inhabitants. Con- 
versely, a village afflicted with goitre has 
been relieved of that disease by changing its 
water supply. 

There are " goitre-wells " on the conti- 
nent, to which young men, who wish to be 
exempt from military service, resort ; after 
drinking this water for a few weeks, they 
obtain goitres sufficiently large for them to 
obtain their wish. 

Mere hardness in the water does not cause 
goitre. Berry believes that there is a defi- 
nite relation between goitre and some 
poison in the soil, which is carried by drink- 
ing water. This may be some mineral in- 
gredient, possibly a salt of some alkali or 
alkaline earth. From personal experiment 
he believes that it is not a salt of lime, 
magnesia or iron. Want of air and sun- 
shine, climatic and atmospheric conditions, 
heredity, habits and intermarriage, have ap- 
parently no share in the causation of goitre. 

The effect of goitre on the duration of life 
is small. In some cases pressure on the 
trachea causes death. Again, if bronchitis 
or some similar disease intervenes, the pa- 
tient has a much smaller chance of re- 
covery. 

In regard to the treatment of goitre, the 
author believes that injections of various 
substances to excite sufficient inflammation 
to obliterate the vesicles of the gland, or to 
have some solvent action on the colloid con- 
tents, is not devoid of danger. Iodine is far 
preferable to every other substance ; yet its 
injection has been followed in a number of 
cases by death. Internal administration of 
remedies is briefly discussed and dismissed. 



The use of setons was wisely abandoned 
long ago. 

A noteworthy series of cases has been re- 
ported by Rydygier, of Cracow, in which 
ligature of the superior and inferior thyroid 
arteries on both sides has been performed. 
In sixteen cases the results were excellent, 
although the operation is a difficult. one, and 
the patients have not been watched for suffi- 
cient time. Cystic or fibro-adenomatous 
goitres are less likely to be benefited by such 
ligation. Division and resection of the thy- 
roid isthmus have been less successful ; the 
operations have been followed by death in 
some cases, or the dyspnoea, for relief of 
which the operation was done, was unim- 
proved. Total extirpation of the gland is 
not recommended on account of its grave 
dangers. Partial extirpation has been done 
by Berry, frequently with good results. 
Mulculiczs resection, which consists in re- 
moving the chief part of a lateral lobe, 
avoiding the recurrent laryngeal nerve by 
leaving the portion of the gland adjacent 
intact, has the advantage that it leaves suffi- 
cient gland tissue to prevent cachexia 
strumipriva, avoids haemorrhage and injury 
to the recurrent laryngeal nerve, and re- 
moves the capsule of functionally useless 
gland tissue. There has never been a return 
of the goitre in the portion of gland in 
twenty-three cases operated on according to 
Mukulicz's method, nor impairment of 
health, although one case died of recurrent 
haemorrhage and one required a tracheo- 
tomy. 

In 550 cases of partial thyroidectomy 
only six j^i'esent symptoms of cachexia 
strumipriva ; five of these recovered and one 
died. In cases of cachexia strumipriva, 
transplantation of thyroid tissue, as done by 
Kocher, Horsley and Fenwick, can be tried. 
Pilocarpin, jaborandi and nitro-glycerin 
should be of service. In malignant goitre 
no operation but tracheotomy is advisable. 
Kocher has reported the results of 250 con- 
secutive operations on goitre, with a mor- 
tality, if malignant and exophthalmic 
goitrous disease be eliminated, of 0.8 per 
cent. Cachexia strumipriva is the most im- 
portant remote effect of thyroidectomy ; the 
existence of this remarkable affection, fol- 
lowing the operation, was drawn to the at- 
tention of the profession in 1883 ; its recog- 
nition had a great effect in modifying views 
held in regard to thyroidectomy. Berry be- 
lieves it can be avoided by performing 
partial thyroidectomy. — Univ. Med. Mag. 



70 



Periscope. 



Vol. Ixvi 



CLINICAL STUDY OF THE CONDITION OF 
THE HEART IN TYPHOID FEVER. 

Dr. L. Galliard, (Archives Generales de 
Medicine) took careful notes of the anoma- 
lies in the condition of the heart during an 
epidemic of typhoid fever in Paris, in 1880, 
while he was interne under Professor Hayem 
in the Saint Antoine Hospital. He had 
delayed 'publishing the notes, as he had 
hoped to have made further investigations 
on the subject, but circumstances prevented 
him, he simply gives the clinical notes of the 
cases as they were taken at the time. 

The first case was one of sudden death at 
the end of the first week of the disease. The 
patient was progressing favorably, the tem- 
perature 37.8° C. in the morning, and 40.2° 
C. in the evening, when he became delirious, 
and after a short time died. No cause could 
be found in the post mortem examination to 
account for the death. 

The second case was one of collapse on the 
thirteenth day. There had been profuse 
diarrhoea, and the temperature from 39.5° 
C. on the eleventh day, gradually sank to 
36.1° C. in the armpit, and 37.4° C. in the 
rectum on the thirteenth. He presented all 
the appearance of a cholera patient, with 
cold extremities, livid face, almost pulseless, 
and no heart sounds to be heard. Under 
stimulating treatment he gradually recov- 
ered. 

The third and fourth were cases of non- 
rhythmical intermittence of the pulse, the 
third exhibiting the intermission only on the 
day of entry [the eighth of the disease]. 
There was a murmur [systolic ?] at the apex 
and at the base of the heart. In the fourth 
case, the intermissions continued from the 
8th to the 24th day. There was slight albu- 
minuria. 

The fifth was an ansemic girl, in whom 
rhythmical intermissions occurred after de- 
fervescence — from the 24th, and lasting three 
weeks. There was also systolic murmur at 
the apex and in the pulmonary area. In 
the sphygmographic tracings there occurred 
an occasional double pulsation. The patient 
had also a slight relapse. 

The sixth case was at first simply asthenic, 
with feebleness of the apex beat, and of the 
heart sounds. There were intermissions on 
the 24th day when the fever was abating. 
Pneumonia ensued, and the patient died. 
There was myocarditis. 

The seventh case had untractable diar- 
rhoea. At the end of the third week there 
was feebleness of the heart and faint first 
sound. Later, at the apex, the first sound 
could scarcely be perceived while heard dis- 



tinctly over the sternum. There was also 
inequality and irregularity in the pulse 
beat. The patient died suddenly about the 
end of the fourth week. Myocarditis and 
vitreous degeneration of the voluntary mus- 
cles were found. 

In the eighth case there was systolic mur- 
murs at the base and apex observed on the 
eighth day of the disease, disappearing on 
the tenth from enfeeblement, and the patient 
died on the twelfth. There was myocar- 
ditis. 

The ninth case was somewhat similar to 
the eighth. 

In the tenth there were anaemic murmurs 
that persisted after recovery and the author 
points out the necessity to distinguish 
ansemic murmurs from murmurs arising in 
cases of myocarditis. 

The next three cases are examples of the 
true cardiac form of typhoid fever. There 
is a general resemblance in all these cases — 
intermissions of the heart's action coinciding 
with the murmurs, or following on the dis- 
appearance of the heart's sounds, and feeble- 
ness of the apex beats. Towards the end 
the heart's action becomes irregular, accom- 
panied by tachycardia, and is premonitory 
of a fatal termination, and finally syncope, 
preceding death. There were also compli- 
cations in the lungs, kidneys, nervous sys- 
tem, etc. In the three cases given myocar- 
ditis was demonstrated in each one. 

The last two cases of endocarditis, the 
murmurs appearing in the one case on the 
eighth day, and persisting after recovery, 
and in the other case acute endocarditis was 
diagnosed before the symptoms of typhoid 
fever developed, the murmurs persisting here 
also after recovery. 

The author concludes with a few remarks 
on the causes of the cardiac phenomena, 
pointing out that, in addition to the local 
mischief, affections of various nerve centres 
would account for some symptoms. In 
treatment, he strongly recommends the judi- 
cious and bold use of digitalis. 



SURGERY. 



ARTHROTOMY IN OLD LUXATIONS. 

V. Vaurossy (Wien. hlin. Woch., 1890, 
No. 50). V. reports from the Innsbruck 
clinic nine cases of old elbow luxations, and 
one each of shoulder and metacarpo-phalan- 
geal of the thumb. The elbow luxations 
consisted of backward dislocation of both of 
the forearms. Either the external or in- 
ternal epicondyle, or both, as in one case,. 



January 9, 1892. 



Periscope. 



71 



served as barriers to reduction by being 
forced into the joint. The longest duration 
of the luxation was twenty-four months. 
The younger the individual and the luxa- 
tion, the more favorable the prognosis. The 
cartilaginous covering of the articular ex- 
tremities of the bones suffers less in young 
individuals, in case of luxations of long 
standing, than in olders ones. 

In performing arthrotomy in these cases, 
the joint was opened from both sides. The 
author, as a result of his experience, de- 
clares that by means of arthrotomy a much 
better result is reached than by a most 
economically planned resection. Subcu- 
taneous separation of the intra-articular 
bands which form in these cases the author 
declares to be entirely insufficient. 



MODERN RENAL SURGERY. 

Dr. A. Obalinski sums up his views re- 
garding the treatment of severe inflamma- 
tory affections of the kidneys and their 
sequelae in the following way: 1. Suppura- 
tive inflammation of the Iddney and sur- 
rounding structures indicates the operation 
of nephrectomy in order that free exit 
may be given to the purulent and other in- 
flammatory excretions, and that the focus of 
the diseased may be thoroughly cleansed, 
and further extension of the suppuration to 
important parts, as, for example, the thoracic 
and abdominal cavities and the hipjoint, be 
thus prevented. In most cases the single 
lumbar incision, as was performed by 
Simon, will suffice, but when there has been 
extensive undermining of the peritoneum the 
formation of a large flap, as practiced by 
Bardenheur, is to be preferred, as such oper- 
ation permits of ready access to all exten- 
sions of the main pus-containing cavity. 2. 
Urethral fistulse should always be treated by 
removal of the corresponding kidney, pro- 
vided the surgeon can assure himself of the 
existence of a sound renal organ on the 
other side. Nephrectomy in such cases is 
indicated, not only on subjective grounds 
and when, for instance, the external flow of 
urine cannot be restrained by any apparatus 
and the patient is thus prevented from fol- 
lowing his occupation and from enjoying a 
comfortable existence, but also on objective 
grounds, since, notwithstanding the utmost 
precautions, an old ureteral fistula may re- 
sult in suppurative inflammation of the cor- 
responding kidney and of the adjacent soft 
parts. 3. Nephrectomy performed under 
these last mentioned conditions oflers much 
less favorable prospects than in cases in 



which there is an absence of suppuration or 
of cicatricial adhesions. 4. There can be no 
doubt that, under equally favorable condi- 
tions, the transperitoneal method can be per- 
formed more rapidly and with greater ease 
than the extraperitoneal method of nephrec- 
tomy, and that the progress toward recovery 
is more speedy after the former operation. 
The transperitoneal method, however, is not 
applicable to every case, and should be re- 
served for those instances in which the mis- 
chief is confined within the capsule of the 
kidney, the extraperitoneal method being 
indicated when the suppurative process has 
involved the perirenal structures. — Yolh- 
mann's Sammlung Klinische Vortrdge. 



RESECTION OF THE SKULL IN TRAU- 
MATIC EPILEPSY. 

Dr. A. Garibaldi (Gazz. degli Ospitali, 
October 4th, 1891) reports the case of a 
man, aged 28, who, ten years previously, 
had fallen from a considerable height on his 
head, sustaining a compound comminuted 
fracture of the skull in the right fronto- 
parietal region. After this accident he be- 
came subject to epileptic attacks ; these were 
at first partial, starting from the left leg, 
particularly the flexor muscles ; during them 
the man was dazed, but did not lose con- 
sciousness. The attacks gradually became 
more frequent, until they occurred two or 
three times a week. On examination an 
irregular cicatrix was found on the right 
side of the skull directed obliquely from 
without inwards, from below upwards, and 
from behind forwards. The scar was about 
8 centimetres in length, and at its middle 
part about 3 in breadth ; at this point 
irregular bony prominences and depressions 
could be felt. On measurement the scar 
was found to correspond to the upper part 
of the prerolandic convolution and the first 
and second frontal convolutions. On April 
29th, 1891, Dr. Garibaldi operated. He 
first removed the whole of the bony cicatrix, 
resecting with the scalpel the cranial bones 
around the scar, and in this way making a 
breach in the skull of about 4 square centi- 
metres in extent, and exposing the dura 
mater over the whole area. In the anterior 
part of the wound a swelling rather larger 
than a hazel nut, and containing serous fluid, 
was opened. There was a little haemorrhage 
from the diploe and the dura mater on 
breaking down some adhesions ; with this 
exception there was no complication. The 
operation was performed with the strictest 



72 



Periscope. 



Vol. Ixvi 



antiseptic precautions. Recovery took place 
without interruption ; the wound healed 
almost entirely by second intention, as the 
skin flap, which consisted of old cicatrical 
tissue, partly sloughed. At the date of the 
report the cicatrix was fibrous and resistant. 
With regard to the fits the result was only 
moderately satisfactory. With the excep- 
tion of a slight attack, which occurred the 
day after the operation, there were no further 
seizures until May 22nd, when general con- 
vulsions occurred twice. On the following 
day the patient complained of cramps in the 
lower limb, and on the night of June 5th 
another attack occurred, which was followed 
by headache. On June 30th and again on 
July 5th he had attacks during the night. 
On July 15th one took place during the 
day, and other attacks occurred at the 
end of the same month and at the be- 
ginning of August. The patient cannot, 
therefore, be considered cured, and there is 
little hope of much further improvement as 
time goes on. — Bvit. Med. Jour. 



THE TREATMENT OF VARICOLA. 

According to Dr. Landerer, the extirpa- 
tion or obliteration of varicose scrotal veins 
is apt to be followed by relapses. In one of 
his cases of recurrence he obtained an ex- 
cellent result by letting the patient wear a 
hernia truss with movable pad, according to 
the method of Ravoth. One and a half 
years after application of the truss thevarix 
had disappeared completely, and after wear- 
ing it for a year longer it was left ofi", and 
since eight years, there has been no return 
of the varicocele. An equally successful 
result was obtained in three other cases. 
The truss probably acts as an artificial sub- 
stitute for the valves of the veins which have 
either completely disappeared in the vari- 
cosities or are in a rudimentary condition. 
This procedure is also apphcable to varices 
of the lower extremities. For this purpose 
the author makes use of an apparatus con- 
sisting of a curved spring and a pad filled 
with water, which is made to press directly 
upon the saphena vein. He has employed 
this truss in eighty cases with very satisfac- 
tory results. Its application is much more 
agreeable to the patient than bandaging, 
and then it is much cheaper than an elastic 
stocking. Under the use of the apparatus 
a reduction in the size of the limb has been 
observed, but the treatment must be regarded 
as palliative rather than curative. — Deut. 
Medizinal-Zeitung. 



MECHANISM OF FRACTURES IN THE 
DORSAL AND DORSO-LUMBAR REGION 
OF THE VERTEBRAL COLUMN. 

In r Union Medicale, July 2, 1891, Dr. 
J. Menard gives the following conclusions : 

(1) Indirect fractures are most common 
and are produced by forced flexion, 

(2) There is first a sinking, then tearing, 
then breaking, the last often independent of 
the tearing. 

(3) Simple sinking, constantly found in 
dorso-lumbar region, is not known in dorsal 
region. 

(4) Breaking more frequent in dorsal; 
the tearing exists in both regions. 

(5) Ordinary cause of dorso-lumbar frac- 
tures arise from falls upon the seat of lower 
limbs ; more rarely from bodies pressing on 
the nape of the neck and top of back, mth 
flexion of trunk. 

(6) Dorsal fractures from falls on the 
nape of the neck or from flexion caused by 
pressure on nape of neck, and top of back — 
the trunk being vertical. 

(7) With dorsal fractures, there are 
almost always fractures of the ribs, some- 
times of the sternum. 

(8) Compression of the cord generally 
caused by the posterior superior border of 
the inferior fragment of the body of the 
vertebra. 

(9) The indication is to reduce and main- 
tain reduction for a sufficient time. 

(10) Trephining is seldom indicated and 
should be reserved for mixed fractures and 
crushingsof the posterior arch, — Univ. Med. 
Mag. 



AN OPERATION FOR TETANOID 
CONVULSIONS. 

The Centralblatt fur hlinische Medicin 
refers to a case of Mr. T. R. Ronaldson's, 
recorded in the Edinhurgh Medical Journal, 
in which a perfectly healthy child was 
attacked with tetanus on the eleventh day 
after birth. The birth had been a normal 
one, except that the child had a very thick 
umbilical cord. On examination, the stump 
w'as found . discolored and foul-smelling. 
Symptoms of inflammation had not been 
present. Frequent washings with a corro- 
sive-sublimate solution was carried out and 
everything was done to prevent a recurrence 
of the convulsions, but without avail. On 
the twenty-third day the author performed 
excision of the navel, with the result of the 
gradual diminution of the frequency of the 
attacks. By the end of the seventh week 
the convulsions had entirely disappeared 



January 9, 1892. Periscope. 



73 



and the child was restored to perfect health. 
There was no micro-organisms found in the 
excised umbilical stump. 



LAPAROTOMY FOR WOUNDS OF THE 
LIVER. 

Broca {Le Merer edi Medical, 1891, No. 
29) reports two cases of wound of the liver, 
each treated by surgical intervention, and 
each terminating fatally. 

The first patient was seen six hours after 
the infliction of the stab wound. He ex- 
hibited the symptoms of large haemorrhage. 
The wound was enlarged; the source of 
bleeding was found to be the liver ; blood 
was flowing freely from the incision upon the 
anterior surface of this organ. An attempt to 
suture this wound proved futile, the threads 
tearing through. Thermo-cautery also failed 
to check the bleeding ; an iodoform tampon 
was, however, entirely successful. An hour 
was consumed in the operation. 

The patient perished two days later of 
abdominal septicaemia. 

At the autopsy several other wounds 
were found, in some of which there had been 
bleeding after operation. 

The second case was also a stab wound. 
The patient was seen four hours after the 
injury, and presented all the symptoms of 
intra-peritoneal haemorrhage. The abdo- 
men was opened and a non-penetrating and 
penetrating wound of the stomach were 
found. A wound three inches long was 
observed on the lower surface of the liver. 
By means of a silk suture this wound was 
closed and the bleeding ceased. The pa- 
tient died in a few hours with symptoms of 
continued haemorrhage. 

At the autopsy it was found that the 
knife had passed completely through the 
Hver, the w^ound of exit being located on the 
upper surface of this organ one-flfth of an 
inch behind the suspensory ligament. From 
this source sufficient blood flowed to entirely 
fill the pelvis. — Amer. Jour. Med. Sci. 



AN IMPROVED METHOD OF GRAFTING 
ULCERS. 

Dr. Gill in a letter to the Lancet, says that 
having had an exceptionally large number 
of chronic ulcers of the leg, which incapaci- 
tated the patients from work, and finally 
brought them into the infirmary, he tried the 
ordinary methods of grafting, but being dis- 
gusted with the very large number of total 
failures, he experienced, he undertook var- 
ious experiments, and at last adopted the 



following plan, which he distinctly disclaims 
as his own, but which consists in adopting 
and combining the ideas of several people. 
The success he obtained with this method 
was so marked that he thinks a large num- 
ber of practitioners at home and abroad (in 
India especially, where he found all ulcers 
very intractable under ordinary treatment) 
will Avelcome it. Even when the ulcer is 
deep, with hard thickened edges and extend- 
ing all around the limb, the method applies. 
This is to cleanse the surface well for two or 
three days with boracic fomentations, and 
then (contrary to what he was taught) 
slightly abrade the granulations, just suffi- 
cient to cause oozing, and apply the graft 
directly to the abraded surface, where it is 
held in position by a small pile made of 
half-inch squares of green protective, four 
or five squares being placed one on the top 
of the other. A graft is thus applied to 
every square inch of surface. And now comes 
the most important thing of all, and which 
is an idea he received from a friend. This 
is to encircle the limb with a fold of carbolic 
gauze, which extends two or three inches 
above and below the ulcer, where it is 
attached to the sound skin by collodion. 
The ulcer is then thoroughly dredged with 
boracic powder through the gauze, and the 
whole is wrapped in a layer of wet boracic 
lint, which is kept thoroughly moist. As a 
rule, the dressing is not disturbed for three 
days, when the lint is removed, and the limb, 
Avell irrigated with boracic lotion, the grafts 
remaining perfectly secure under their heaps 
of protective, which again is kept in position 
by the gauze. The limb is then redusted 
with boracic powder, and done up in the 
w^et lint, which is now changed daily. At 
the end of ten days the gauze and protective 
are removed, and each graft will be found 
as large as a sixpence, while those near the 
edges will have exercised a spermatic influ- 
ence, and caused a rapid ingrowing of epthe- 
lium. Since adopting the above plan Dr. 
Gill says that he has never lost a single 
graft, though employed on most unfavorable 
surfaces — a very different result to the old 
way of covering the grafts with a large 
piece of protective which retained some 
exudations under it, and thus bathed the ten- 
der graft in a poisonous medium, with a re- 
sult that 80 per cent, of them never "took." 



IODINE WATER AND ARISTOL AS SURGI- 
CAL ANTISEPTICS. 

Popoff speaks very highly of the antisep- 
tic effects of irrigations with iodine water 



74 



Periscope. 



Vol. Ixvi 



(1 to 10,000), and consecutive powdering with 
aristol (pure or in a form of a 20 per cent, 
mixture with boracic acid) in cases of tuber- 
culosis of joints (fungating arthritis, etc.) 
and bones, callous syphilitic ulcers, simple 
chronic ulcers, angina Ludovici, phlegmon, 
furunculosis, wounds of every description, 
etc.* The iodine lotion also gives excellent 
results in inveterate ozsena. In addition to 
its powerful antiseptic properties it has a 
decided astringent and hsemostatic action. 
Under its use luxuriant and profusely bleed- 
ing granulations rapidly assume a normal 
appearance, cease to bleed, etc. The iodine 
water likewise speedily checks parenchyma- 
tous haemorrhage from any recent wounds. 



CONCERNING THE TIME AND CAUSE OF 
THE EXTENSION OF GONORRHCEA TO 
THE PARS POSTERIOR URETHRA. 

After an examination of fifty cases of first 
infection of gonorrhoea. Dr. Ignatz Heisler, 
(Archiv. fur Dermatologie und Syphilis, 
1891, 5 Heft.) concludes : 

1st. That posterior urethritis appears 
much earlier than is usually taught and 
accepted by the best writers. 

His statistics show that in twenty per 
cent, of the cases it appeared in the first 
week, in thirty-four per cent, in the second 
week, and in fourteen per cent, in the third 
week after the appearance of the discharge. 

2d. Constitutional afiections, especially 
syphilis, have little influence in hastening 
the occurrence of posterior urethritis, 
although the affection occurs more frequently 
in syphilitic subjects. 

3d. Occupations which necessitate long- 
continued exertion play an important role 
in expediting afiections of the deep urethra. 

4th. The afiection is equally prevalent 
whether injections are used or the treatment 
be confined to internal medication. 

5th. The musculus compressor urethrse 
has no power to prevent the transference of 
the infective agent to the deep urethra. 

6th. The gonorrhoeal inflammation of the 
anterior urethra cannot be regarded as an 
afiection of such typical course as is asserted 
by the majority of authors, i. e., an inflam- 
mation starting in the fossa navicularis, 
reaching the bulb in three weeks; then, 
when the acme of intensity is attained, pass- 
ing over to the posterior urethra. In the 
great majority of the cases, this happens 
during the first or second week without the 
direct transference of the gonorrhoeal pus by 
means of catheters or sounds. 

It must therefore be looked upon, not as a 



complication of anterior urethritis, but as a 
direct continuation of it. 



SUTURING OF NERVES. 

Th. Kollker (Deutsch Chir., 189, Liefg. 
246, Stuttgart, Ferd Enke, 1890). The dis- 
cussion of the interesting question of primary 
union of divided nerves, as well as the pro- 
cesses of degeneration and regeneration, is 
entered into in connection with the subject 
of nerve suture and operations upon nerves. 
The author's researches, to be published 
later, show, contrary to Friedlander and 
Krause, degeneration of all of the fibres of 
the peripheral nerve stumps, the latter, 
according to Kolliker taking no active 
part in the process of regeneration, but 
simply serving as a guide for the newly- 
formed nerve fibres in their passage from 
the central nerve stump to the periphery. 
Immediate contact of the severed axis 
cylinder may possibly lead to immediate 
union of the same, but there is no indubit- 
able evidence of this having occurred. 
Union by formation of a small amount of 
new-formation tissue, with the development 
of nerve fibres as demonstrated by the 
microscope, without degeneration of the 
distal ends of the nerves, according to K., 
has occurred. 

In suturing nerves, Kolliker does not 
employ one method to the exclusion of the 
rest. In cases in which the ends can be 
brought together only after considerable 
force, the direct method is indicated; in 
cases in which there is no tension, the 
indirect plan is adopted. Silkworm gut, or 
catgut, is employed as a suture material. In 
cases in which there is a deficiency to the 
extent of 4 ctm., due to removal of a section 
of the nerve, he recommends stretching the 
nerve to fill the gap, and subsequent sutur- 
ing. In cases of a more considerable gap, 
Vanlair's method of tubulization, or union 
by means of catgut loops, is preferable to 
nerve transplantation. In cases in which 
the central end of the injured nerve cannot 
be found, imjDlantation of the distal end to a 
neighboring nerve is recommended. This 
method of " neurotization " whereby the 
distribution to a distant part is effected 
through the medium of a nerve trunk not 
originally destined for this purpose, promises 
to be a valuable aid in cases otherwise hope- 
less. 



The Debility following Influenza is said 
to be greatly benefited by anacardium occi- 
dentale (cashew nut). 



January 9, 1892. 



Periscope. 



75 



GYNJEOOLOGY. 



NOTE ON THE VALUE OF IGNIPUNCTURE 
IN THE TREATMENT OF HYPERTRO- 
PHIED CERVIX UTERI. 

Dr. Alexander Duke, writes in the Lan- 
cet that the length of time occupied by the 
usual routine treatment of a case of chronic 
hypertrophied cervix uteri can be considera- 
bly shortened by the judicious use of igni- 
puncture. The usual plans of treatment — 
viz., tampons of glycerine, copious syring- 
ing with very little hot water, painting cer- 
vix with Churchill's tincture of iodine, etc., 
— occupy a very considerable time, which 
prolonged treatment (unless the patient is 
able and willing to pay for) " is more hon- 
ored in the breach than the observance." 
Superficial firing by caustics or smouldering 
pieces of carbon held in contact with cervix 
by forceps is not sufiicient in well-marked 
cases of chronic hypertrophy to obtain the 
desired result within a reasonable time. 
Having observed the good effects on enlarged 
tonsils by the employment of igni puncture, 
he has given it a trial, and can strongly 
recommend it as a useful adjunct in these 
cases. A ther mo-cautery of small size and 
point (Paquelin's) will be found the best for 
the purpose, but those who do not possess 
this valuable instrument can obtain equally 
good results with a copper rod, sharp at the 
point, and with solid bulb about half an inch 
from the top, so as to retain the heat while 
the necessary number of punctures are made 
through a wooden or celluloid cylindrical 
speculum. This cautery can be heated with 
an ordinary spirit lamp till red-hot, held in 
the tissues for a few seconds, while each 
puncture, about a quarter of an inch, is 
made, and then withdrawn. There should 
be no bleeding observable if the operation 
has been properly performed, such being 
caused by the cautery being either too hot 
or too cold. His usual practice is to blow a 
little boric acid (with his vaginal insufflator) 
over the punctured surface, and make no 
examination for about a week, when the 
operation can be repeated if necessary. He 
has also found ignipuncture of great value 
in lacerations of the cervix when hardly bad 
enough to demand Emmet's operation. Lit- 
tle pain, if any, is produced unless the oper- 
ator is unwise enough to allow the patient 
to observe the preliminaries. 



A Faculty of Medicine is about to be 
established in Constantinople. 



REMARKS ON A SERIES OF ONE HUN- 
DRED LAPAROTOMIES. 

Ten years ago to-day. Dr. Joseph Taber 
Johnson says, he performed his first lapar- 
otomy on a lady completely broken down, 
mentally and physically, on account of 
menstrual epilepsy. When he heard from 
her last, she was alive and doing well — not 
a " brilliant cure in sixteen days," but so 
much improved as to induce her to write 
that she and her family were very glad the 
operation had been done. 

His next case occurred two years later ; 
she also recovered. His next three cases 
died. None of them suffered from the four 
principal causes of death following lapar- 
otomy — shock, haemorrhage, peritonitis, or 
sepsis. But still, he began at once to study 
over again his abdominal surgery, and in 
the hope of doing better work in future, 
took lessons from the best operators across 
the ocean, as well as in our own country. 
He saw Tait perform twenty-three abdom- 
inal sections. He studied the methods of 
Keith, in Edinburgh, Bantock and Thorn- 
ton, in London. He had previously seen 
Sir Spencer Wells operate. 

He saw operations under clouds of car- 
bolic spray, and without spray. He saw 
every detail and variety of antiseptics used, 
and other operations, equally, if not more 
successful, where only ''surgical cleanli- 
ness " was observed. He made many trips 
to New York, Philadelphia, and Baltimore 
upon invitation and toleration to study the 
methods of our most successful abdominal 
surgeons, in all witnessing and assisting, 
where he could, in at least two hundred 
laparotomies for a great variety of condi- 
tions. 

After this increase of experience with 
men and methods, he had a run of 25 
ovarian operations without a death; the 
twenty-sixth case died. Another run of 
fourteen cases without a death ; the fifteenth 
died of tetanus the fourteenth day after the 
operation. Another run of thirty- three 
cases without a death — making a new series 
of seventy-three ovarian operations, with 
seventy-one recoveries and two deaths. The 
first series of five cases had three deaths. 

In this report of 100 consecutive lapar- 
otomies, he only proposes to discuss, briefly, 
the value of surgical interference in some of 
the different groups of cases embraced in the 
accompanying table. 

Laparotomy was done for the — 
Removal of uterine appen- 
dages, 42 times with 3 deaths. 

Ovarian tumors, ... 37 " 2 " 



76 



Periscope. 



Vol. Ixvi 



Uterine fibroids, supra-va- 






ginal hysterectomy, . . 


12 


" 4 « 


Csesarean section, . . . 


1 


1 " 


Hydro-nephrosis (74 lbs), 


1 


" 1 " 


Exploratory laparotomies, 


3 


" 


Universal cancer, 


1 


1 « 


Ruptured tubal pregnancy 






(supposed), .... 


1 


" 1 '« 


Chronic peritonitis, . . . 


1 





Laparotomy for abdominal 








1 


" 




100 


u 13 u 



HYDRASTININ IN METRORRHAGIA. 

Folk (^Centralhlatt fur GyneJcologie,l^o.8, 
1891.) has found that hydrastin is a 
heart poison, while hydrastinin is not. 
The latter has the advantage over hydrastin 
of producing considerable and regular vas- 
cular contraction. This conclusion was based 
upon the results obtained from treating 
twenty-eight cases of metrorrhagia from 
hyperplastic endometritis, congestive dys- 
menorrhoea and metrorrhagia accompanied 
by vertigo. In the former the metrorrhagia 
diminished. The chloride of hydrastinin, 
in a 10 per cent, solution in water, in doses 
of 5-10 cgr. gr.) is the preparation 

employed. It should be especially used 
before and during the time when haemor- 
rhage occurs. 



OBSTETRICS. 



HYPEREMESIS GRAVIDARUM, PTYALISM 
AND HYSTERIA. 

Ahlfeld {Centralhlf. Gyn.,^o. 11, 1891). 
Kaltenbach in a recent paper has called 
attention to the frequency with which the 
hyperemesis of pregnancy occurs in hysteri- 
cal patients and to the fact that the thera- 
peutic measures which prove most success- 
ful in the treatment of hysterical manifesta- 
tions have a favorable influence in the former 
affection. Yet he does not claim that the 
pernicious vomiting of pregnancy can be 
directly traced to hysteria. The author has 
met with several cases in which hysteria was 
the principal foundation of the uncontroll- 
able vomiting. He regards both the hyper- 
emesis and ptyalism of pregnancy as noth- 
ing more than an exaggeration of the reflex 
neurosis common in pregnancy in many 
women. His management of these cases is 
precisely the same as in hysteria uncompli- 
cated with pregnancy. He enforces rest, 
forbids intercourse with friends and pre- 
scribes all mental excitement. His results 
he claims substantiate his doctrine. 



Apropos of this question are the following 
remarks from the editorial columns of "Brit. 
Med. Journal " of May 30th, 1891 : 

This subject, of so deep interest to the 
practitioner, is at present occupying the 
attention of a large number of British and 
foreign obstetricians. Sixteen years ago 
there appeared in the journal the now cele- 
brated paper by Dr. Copeman, which was 
read all over the globe, and gave his name 
to the " method " he advocated. Copeman's 
method simply means dilatation of the cer- 
vix with the finger. Undoubtedly it has 
proved of the highest service, whatever may 
be of the precise nature of its action. Dr 
Graily Hewitt, whose work on Severe Vom- 
iting during Pregnancy appeared last year, 
traces the disorder to flexions, with inflam- 
matory changes in the uterus. . . Other 
authorities refer the trouble to lesions of the 
cervix, and treat them with counterirritants. 

. . . There remains, unfortunately, 
the fact that in many cases nothing stops 
the vomiting save termination of the preg- 
nancy. The induction of labor is not with- 
out risk ; the practitioner is unwilling to re- 
sort to it when the vomiting has not lasted 
long, whilst later on the patient may be 
fatally enfeebled by constant sickness ; hence 
the gravity of the entire question becomes 
self evident. No wonder so much is written 
on hyperemesis graviadarum, but much 
more remains to be done before anything like 
a sound routine practice, suitable to others 
than hospital obstetricians of extremely 
specialized experience, is established to the 
benefit of humanity and the comfort of the 
practitioner. 



PREGNANCY AND HEART DISEASE. 

Dr. S. Remy {Arch, de Tocol. et de Gynec, 
August, 1891) publishes an instructive series 
of cases of death late in pregnancy from 
heart disease. The fatal event is sometimes 
sudden, taking place during work, dancing, 
or getting up. More often it follows asys- , 
tolic phenomena. In the 15 cases collected 
by Dr. Remy the child was extracted, either 
by Csesarean section or version, seven times ; 
three were alive ; in two of these three cases, 
if not in the third, death of the mother had 
been sudden. One foetus extracted after 
" some delay " (precise length of time not 
being noted), was not quite pulseless when 
born. In cases of sudden death, the chance 
that the child may be living when the 
obstetrician acts promptly is considerable. 
When the mother has died from slow 
asphyxia due to asystolism, the child has 



January 9, 1892. ' Periscope. 



77 



probably expired before its parent. In a 
case of this kind under Dr. Remy's own ob- 
servation the child, promptly delivered by 
version, was beginning to macerate ; it 
had evidently been dead for two days or 
more. The question of hastening delivery 
is grave. The actual birth of the child by 
premature delivery, when safely ended, 
leaves the woman for the time better off than 
before labor. Unfortunately premature 
labor in heart disease does not always im- 
prove the patient's condition. The cardiac 
and secondary lesions may be too serious to 
permit of more than the most temporary 
benefit. The labor itself places the patient 
for the time in extreme peril of fatal asys- 
tolism. Lastly, there remains a third fact, 
which may not be taken into account at the 
beginning of the case, when the induction of 
labor is contemplated. In lying-in patients 
with heart disease, severe cardio-pulmonary 
complications often set in on the third or 
fourth day after labor. Altogether it would 
appear best to induce abortion very early 
when cardiac disease, with grave complica- 
tions, is present in a pregnant woman. 
Obstetricians may hesitate to take such a 
step, as they may wish to extract a viable 
child, and, as this involves some interval of 
time, the cardia symptoms may undergo 
some amelioration, or in some cases the child 
may die and be readily extracted. Hence 
it is hard to lay down a general rule ; much 
must depend on the gravity of each individ- 
ual case. — Brii. Med. Jour. 



PREGNANCY AT THE AGE OF FIFTY-NINE. 

Dr. E. Derasse ( Gazette Medicale de Liege, 
October 1st, 1891) saw in his consulting 
room in August, 1889, a lady with a swell- 
ing of the abdomen. She was 59 years of 
age, and had been a widow for twenty years. 
The tumor was taken, by one of her medical 
attendants, for a uterine fibroid, and by an- 
other for a cyst. Arrangement had even 
been made for an operation. Dr. Derasse, 
on examining the tumor, which was uniform 
with the uterus, noticed a sensation as 
though something was moving inside it. On 
auscultation foetal heart sounds could be 
heard ; ballotement was also clear. The 
breasts were already well developed and 
heavy. After careful investigation of the 
case it transpired that the elderly patient 
had a young lover. On December 21st, 
1889, she was delivered of a fine boy. She 
was then aged 59 years and 5 months, Dr. 
Derasse having succeeded in obtaining her 
birth certificate. She suckled her child 



well, and weaned it upon her sixtieth birth- 
day. She stated that she had ceased to 
menstruate at 50 and she had a married 
daughter 40 years old. Dr. Derasse refers 
to the Dictionnaire Encyclopedique where 
several cases are recorded where mothers 
suckled their children at the age of 60, or 
even later. — Brit. Med. Jour. 



PEDIATRICS. 



THE FREQUENCY OF INFANTILE CON- 
VULSIONS. 

Dr. G. L. Walton has found that out of 
1,000 children, taken consecutively at ran- 
dom from all classes of society, 11.1 per 
cent, have been found to have a history of 
infantile convulsions. Among epileptics 
whose epilepsy did not begin in infancy, 
seven per cent, had infantile convulsions. 



GONORRHCEAL STOMATITIS IN AN IN- 
FANT. 

Professor Dohrn describes in the Medi- 
cinische-chirurgische Rundschau the case of a 
child, eight days old, which was brought to 
his clinic suflfering with swollen jaws. A 
further examination showed the back of the 
infant's tongue and the roof of its mouth to 
be eroded and covered with a grayish-yel- 
low exudation. An acute stage of purulent 
conjunctivitis being present, the mother was 
questioned as to the possibility of gonorrhceal 
infection, and her answers confirmed the 
suspicion of this being the source of the 
trouble. To be positive, however, a small 
portion of the diseased mucous membrane of 
the mouth was excised and submitted for 
microscopical examination, and numbers of 
gonococci were found. It was supposed 
that infection took place upon the abraded 
mucous membrane in the child's mouth, the 
mechanical injury having possibly been in- 
flicted by the accoucheur. 



ANTIPYRETICS IN CHILDHOOD. 

R. Demme (Jahr.f. KinderJilkde, Bd. 
xxxiii, H. 1 and 2) gives the results of expe- 
rience with various antipyretics in the Jen- 
ner's Hospital in Bern. They were only 
given at all in cases in which the tempera- 
ture exceeded 103° F. for several days; in 
milder cases cold applications or cold baths 
were employed (two baths daily at 77° to 
82° F. for five or ten minutes). In articu- 
lar rheumatism he gave sodic salicylate, or, 
if there was a tendency to vomiting and 



78 



Periscope. 



Vol. Ixvi 



diarrhoea, salol. Doses of salicylate, daily, 
2 to 4 years, 7 to 15 grains ; 5 to 10 years, 
15 to 30 grains ; 11 to 15 years, 37 to 45 
grains — of salol, thrice daily, 2 to 4 years, 4 
to 5 grains ; 5 to 10 years, 8 to 12 grains ; 
11 to 15 years, 12 to 15 grains. In typhoid 
fever thallin sulf. was given every two hours ; 
to a child 3 to 4 years old, \ grain ; 5 to 10 
years, \ grain; 11 to 15 years, i grain to f 
grain. In broncho-pneumonia with very 
high temperature (105° to 106°) he gives 
during the early stage hourly doses of anti- 
pin for two or three doses. Dose, 2 to 4 
years, gr. iss to gr. iij ; 5 to 10 years, gr. 
vij to xij ; 11 to 15 years, gr. xij. to xv ; 
larger doses are unnecessary, and may be 
dangerous. In the latter stage of broncho- 
pneumonia with hectic type of fever, qui- 
nine is superior to every other antipyretic. 
Doses, 2 to 4 years, gr. iij to vj ; 5 to 10 
years, gr. vij to viij ; 11 to 15 years, gr. xij 
to XV. Antifebrin was found particularly 
useful in the high temperature of phthisis ; 
like antipyrin, it sometimes caused a measly 
eruption. Doses, 2 to 4 years, gr. I to j ; 5 
to 10 years, gr. iss to gr. iij ; 11 to 15 years, 
gr. iij to gr. ivss, once, twice, or thrice a day. 
Acetphenetidin was found a very satisfactory 
remedy, but had the disadvantage of 
causing sometimes copious sweats and fre- 
quently a measly eruption and cyanosis ; it 
was best given in single large doses, 2 to 4 
years, gr. iss to gr. iij ; 5 to 10 years, gr. iij 
to vij ; and 11 to 15 years, from gr. vij. A 
new remedy tested by Professor Demme was 
carbonyl-orthoamidphenol, or more shortly, 
oxycarbonil, an isomer of antifebrin which 
is excreted as oxycarbonil. As an antipy- 
retic, it had to be given in larger doses than 
antifebrin, and its action was of very short 
duration, the temperature quickly rising 
again to the point at which it was before. 
Demme states that by repeating the dose 
every two hours, the temperature in typhoid 
may be kept down to 100° to 102° F.—Brit. 
Med. Jour. 



TREATMENT OF DIPHTHERIA BY IRRI- 
GATION OF SALICYLIC ACID. 

In the Bulletin General de Therapeutique 
for September 15th, 1891, Dr. Parisot of 
Voyes publishes a paper in which he highly 
recommends irrigation of salicylic acid as a 
treatment for diphtheria. The former mor- 
tality of his cases was large (10 out of every 
14) ; in a recent epidemic, when the new 
treatment was adopted, he had only five 
fatal cases out of every twenty-four, cer- 
tainly a very satisfactory proportion for such 



a fatal disease. The formula which Dr. 
Parisot employs is as follows : Salicylic acid, 
one gramme water, 980 grammes ; alcohol 
(90 per cent.), 20 grammes. The salicylic 
acid is dissolved in the alcohol, and the 
water added. The apparatus for irrigation 
is a fountain syringe, with the reservoir 
made of tin. This is hung against the wall 
over the patient. The rubber tubing, which 
is connected to a projecting nozzle at the 
lower part of the reservoir, ends in a small 
glass tube drawn out to a point. A spring 
catch on the tube controls the current of 
liquid. When the apparatus is filled with 
the solution the head of the child is held by 
an assistant, the tongue depressed, and the 
jet of fluid directed against the pharynx with 
sufficient force to detach and remove the 
false membranes. Several applications may 
be necessary to effect this, and if the mem- 
branes are not loose a little time must be 
allowed to elapse until this is the case. As 
regards the position of the head. Dr. Parisot 
recommends that this should be forward 
and a little downward. When the child is 
feeble, it should be supported upon the arm 
of the nurse with its face turned towards the 
floor, so as to prevent the liquid flowing 
back and being swallowed in large quanti- 
ties. The amount of fluid used on each 
occasion must be learnt by experience. As 
a rule, three or four ounces each time is suf- 
ficient, and this should be practiced as fre- 
quently as possible. Dr. Parisot considers 
that salicylic acid has a destructive action 
upon diphtheritic formation. He showed 
by experiment that in distilled water the 
membrane simply became sodden and grad- 
ually disintegrated, this taking place very 
slowly, whilst in solutions of salicylic acid 
the membrane was rapidly dissolved ; at the 
end of a few minutes only the meshes of net- 
work in which the cells had been supported 
were visible. The stronger the solution of 
salicylic acid the quicker and more complete 
was the destruction of the tissue. Dr. 
Parisot has further noted that when the 
diphtheritic membrane has been once re- 
moved by means of salicylic acid its repro- 
duction was considerably slower and more 
imperfect, and therefore concludes that the 
acid has a favorable action upon the mucous 
membrane, which is rendered unsuitable for 
the growth of the pathogenic organism and 
the reproduction of the diphtheritic patches. 
— Lancet. 



An hour-glass is made smallest in the 
middle to show the waist of time. 



January 9, 1892. 



Periscope. 



79 



HYGIENE. 



A POISONOUS THIMBLE. 

Among the numberless causes of blood- 
poisoning through the skin, one which was 
lately recorded is worth noting on account 
of its evident simplicity and the ease of its 
prevention. In the case referred to the 
sufferer was a seamstress, and the mischief 
resulted from her using a dirty metal 
thimble marked with verdigris, a little of 
which appears to have entered a scratch on 
the thimble finger. We can well believe 
that this accident was not the first of its 
kind. Verdigris, it is true, is a mere 
metallic irritant, and not comparable in 
virulence to most living germs of disease. It 
is quite enough, notwithstanding, to excite 
local inflammation, which friction, contact 
with dyed cloth material, or the entrance of 
dirt in any form would quickly convert into 
a dangerous and general disorder. There is 
really no excuse for women who trust their 
fingers in these cheap and worse than use- 
less articles. Steel thimbles are much safer 
and cost very little. Another variety also 
in common use is enamelled within, and is, 
if possible, even freer from objection. Let 
us not forget to add a caution that cuts or 
scratches on the hand should never be 
neglected by sewing women so long as dyes 
continue to be used in cloth manufacture. — 
Lancet. 



TUBERCLE BACILLI IN > THE AQUEOUS 
HUMOR OF CATTLE. 

M. Mandereau, of Grenoble, having re- 
cently stated (see British Medical Journal, 
July 4th, 1891, p. 24) that tubercle bacilli 
could be seen in the aqueous humor of 
bovine animals suffering from tuberculosis 
before any other visible sign of the disease 
was present, MM. Leclinche and Greffier 
(Sem Med., July 1st, 1891) made a series of 
observations which, according to them, show 
the statement to be erroneous. They ex- 
amined the eyes of twenty tuberculous oxen, 
and in no single instance could the tubercle 
bacillus be found in the aqueous humor, nor 
did the intra-peritoneal inoculation of that 
fluid in guinea-pigs in any case induce 
tuberculosis in the these animals. — Brit. 
Med. Jour. 



If you are inclined to wonder at the 
number of maladies in the world, you 
should count the cooks. - 



MEDICAL CHEMISTRY. 



HOW TO TEST DRINKING WATER FOR 
IMPURITIES. 

Dr. Frederick J. Wulling, says in the 
Pharmaceutical Era : Sometimes the phar- 
macist is called upon, especially if his sign 
reads " chemist and druggist," to ascertain 
whether a sample of water is fit for drink- 
ing and domestic purposes or unfit for that 
end. It isn't a very difiScult matter to apply 
a few tests for the simple determination of 
the figures or otherwise of a sample in ques- 
tion. A complete examination of the char- 
acter of a sample of water is a very difficult 
problem and should be referred to a skilled 
chemist. The substances to be looked for 
primarily are organic matter, albumenoid 
matter, ammonia, nitrates and nitrites. 

The nitrogen compounds are usually more 
abundant if animal matter is present ; they 
of all other abnormal constituents render 
water the most unwholesome. Their pres- 
ence, and of ammonia and of albumenoid 
substances, do not necessarily render water 
unfit for domestic purposes, but water con- 
taining them or either one usually becomes 
the breeding place of the germs of conta- 
gious diseases if they are around. 

1. For organic matter, put a little of the 
sample into a beaker, add 2 or 3 drops of 
dilute sulphuric acid and color distinctly 
with a solution of permanganate of potas- 
sium. If much organic matter is present 
the color of the permanganate becomes dis- 
charged almost immediately ; if less or very 
little, it takes longer to decolorize. If the 
color has not changed in 25 or 30 minutes it 
is safe to assume that organic matter was not 
present. This is a tolerably reliable test. 

2. For nitrites, a little sulphuric acid 
added to the water forms nitrous acid if 
nitrites are present, which is easily detected 
by its power of liberating iodine from iodide 
of potassium. A little starch paste is mixed 
with a small quantity of a solution of potas- 
sium iodide, and the mixture added to the 
suspected water containing the sulphuric 
acid. If nitrites were present the nitrous 
acid formed liberates the iodine from the 
iodide, which turns blue with starch. This 
indirect method is a ready means for detect- 
ing the nitrites if present in not too small 
a quantity. 

8. Nitrates are detected by converting into 
nitric acid, which turns morphia red. A 
portion of the water is evaporated to dry- 
ness, the residue treated with a drop of 
strong sulphuric acid (which makes nitric 



8o 



Clippings and News Items. 



Vol. Ixvi 



acid of the nitrate) and a portion of mor- 
phine added. If nitrate was present the 
morphine gives red color. 

4. For ammonia, Nessler's reagent is by 
far the best test. It may be made by dis- 
solving 18 grains of oxide of potassium in a 
little water, adding solution of mercuric 
chloride until the red iodide of mercury first 
formed redissolves upon agitation. To this 
is added a solution of 50 grains of caustic 
potassa and distilled water to make 8 ounces. 

This reagent will detect 0.00375 of a grain 
in a pint of water by giving a yellow color. 
A reddish color or precipitate forms with 
larger quantities of ammonia. 

5. Albumenoid matter requires a more 
elaborated proceeding for its detection. If 
all of the above were found it is hardly 
necessary to go to the trouble of looking for 
alburaenoids; the water would be unwhole- 
some even if they were not present. If it is 
desired to test for them, nevertheless. Chap- 
man and Waukly's test is the simplest to 
employ. If the water was found to contain 
ammonia, the latter ipust first be removed, 
as must also any urea that may be present. 
This is best done by distilling the water 
until it gives no reaction with Messler's rea- 
gent. Then add a strong solution of caustic 
potash and potassium permanganate and ex- 
amine again for ammonia. 

This test depends upon the fact that 
caustic potash and permanganate of potash 
cause animal- matter while still in an albu- 
minoid condition to unite with hydrogen to 
form ammonia. 

It must not be understood that the tests 
just given are the only ones; on the con- 
trary there are a vast number, all more or 
less useful, for the determination of the 
quality of a drinking water, but they are 
not all as practical and easily applied. 



Clippings and News Items. 



AN ARMY MEDICAL BOARD. 
Will be in session in Chicago, Illinois, dur- 
ing February, 1892, for the examination of 
candidate for appointment in the Medical 
Corps of the United States Army, to fill 
existing vacancies. 

Persons desiring to present themselves for 
examination by the Board will make appli- 
cation to the Secretary of War, before Jan- 
uary 15, 1892, for the necessary invitation, 
stating the date and place of birth, the 
place and State of permanent residence, the 
fact of American citizenship, the name of 
the medical college from whence they were 



graduated, and a record of service in hos- 
pital, if any, from the authorities thereof. 
The application should be accompanied by 
certificates based on personal knowledge, 
from at least two physicians of repute, as to 
professional standing, character, and moral 
habits. The candidate must be between 21 
and 28 years of age, and a graduate from a 
Regular Medical College, as evidence of 
which, his Diploma must be submitted to 
the Board. 

Further information regarding the ex- 
aminations may be obtained by addressing 
the Surgeon General IT. S. Army, Wash- 
ington, D. C. 



AMERICANS IN THE RIVIERA. 

Dr. Wendt has been commissioned to visit 
the Riviera and the health resorts of the south 
of France in order to study and to report 
on the healthy conditions and the sanitary 
(or insanitary) arrangements, municipal and 
domestic, of the towns and hotels at such 
places as Cannes, Nice, Pau, Hyeres, Men- 
tone, Monaco, San Remo, Alassio, Bordig- 
hera, Florence and Naples. He will find 
much to exercise his industry and acumen — 
much to blame, something to encourage, and 
many causes for warning to his country- 
men. American visitors to the Continent 
are particularly liable to typhoid — of which 
the frequently recurring and sad examples 
are probably the main cause of this journal- 
istic tour of inspection. Part of this special 
liability probably arises from their habit of 
drinking iced water. So long as, following 
the advice of Dr. Herman Weber, they con- 
fine themselves to natural mineral waters of 
recognized purity, they are safe. But these 
are not always at hand, and all do not yet 
understand that icing or aerating polluted 
water detracts nothing from its risks, and 
that even ice itself made from impure water 
is a source of danger. Where only "local 
drinking water" is to be had in the Riviera 
or anywhere on the Continent of Europe, it 
should always be first boiled and then fil- 
tered, as Dr. Gowers advises. — British Medi- 
cal Journal, of Dec. 5th, 1891. 



De. B. W. Richardson describes (As- 
clepiad, XXXI.) some old experiments in 
which he caused local anaesthesia by applying 
the positive pole of an electric battery over 
some narcotic. In many cases complete 
local anaesthesia was obtained ; whilst the 
check experiments of applying the solutions 
and the current separately were followed by 
no anaesthesia. 



Vol. LXVI, No. 3. 
Whole No. 1820. 



M 
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JANUARY 16, 1892. 



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A Weekly Journal. 



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MEDICAL AND 

REPORTER 

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Entered as Second-Class matter at Philadelphia P. 0. P. 0. BOX 843, PHILA., PA. 




CLINICAL LECTURE. 

Prof. Chas. C. Stockton, M. D., Buffalo. 
CEdema as a Symptom Occurring in Malignant Diseases ; Diag 
nosis by Lavage ; Acute Gastritis. 
COMMUNICATIONS. 

A. B. KiRKPATRicK, M. D., Philadelphia. 

Medical Treatment of Appendicitis 
Hbnry R. Smith, M. D., Detroit, Texas. 

Abscess of the Anterior Vaginal Wall. 
Edward Jackson, M. D., Philadelphia. 

Simple Extraction of Cataract. 
Joseph M. Patton, Chicago, 111. 
Kidney Disease with Cardiac Complications. 
SOCIETY REPORTS. 

Philadelphia County Medical Society. 
The Stream of Emigration. 
SELECTED FORMULA. 
EDITORIALS. 

Neurasthenia and its Relations to Mental Diseases. - 



CORRESPONDENCE ..... 

BOOK REVIKWS - - - - - - 

PERISCOPE. 

Therapkutics. 

Hypnotic Action of the Antipyretics — Cornutin as aHajmostatic 
in" Hiemorrhages from Bladder — Chloride of Ammonium in 
Influenza — Hydrotherapy in Treatment of Diphtheria — Treat- 
ment of Angina Pectoris by Cocaine — New Treatment of Gran- 
ular Conjunctivitis — Local and General Anassthesia — Nature 
and Treatment of Stammering — Observations on Use of Piper- 
azine — Action and Use of Filicic Acid — Hypnotism. - 

Medicine ...... 

Surgery ...... 

Obstetrics ...... 

GyNi:coLOGy 

Hygiene ...... 

pediatrics ...... 

Medical Chemistry ..... 

CLIPPINGS AND NEWS ITEMS .... 



100 
102 



102 
107 
110 
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M. D., in 1859. 



Extensive and beautiful grounds. Perfect privacy. A pleasant, safe and healthful 
home. Music, games, open-air amusements. The oldest institution of the kind in the 
United States. Both sexes received. 

ARRANGEMENTS MADE FOR CHRONIC CASES. 

Located a few miles west of Philadelphia, at Primos Station, on the P. W. & B. Railroad, 

REFERENCES: 

» .P^^efsors H.C.Wood, D. Hayes Agnew, Wm. Pepper, Alfred StillS, William Goodell, Roberts Bartholow. 
RA.*. Fenrose, J. IVLDaCosta, Charles K. Mills, James Tyson, and Dr. Lawrence TurnbuU; Professor Wil- 
PeSrSSrg va Hopkins University; W. C. Van Bibber, M. D., Baltimore, Md.; W. W. Lassiter, M/D., 

Resident Physicians: J. WILL0U6HBY PHILLIPS, M. D., S. A. MERCER GIVEN, M. D. 

For further information address 

BURN BRAE, Clifton Heights, Delaware Co. Pa. 



V 



THE 



No. 



CLINICAL LECTURE. 



CEDEMA AS A SYMPTOM OCCURRING 
IN MALIGNANT DISEASES— DIAG- 
NOSIS BY IvAVAGE— ACUTE 
GASTRITIS. 



BY PROF. CHAS. G. STOCKTON, M. D., 

BUFFAI^O. 

Professor of Practice, University of Buffalo ; 
Attending Physician Buffalo General 
Hospital. 



Gentlemen : — This man came to us last 
fall for an opinion as to his condition. 
At the time I found a tumor in the epi- 
gastrium and left hypochondriac region, 
extending from the ribs downward and 
forward to the umbilicus. By a thorough 
emptying of the bowel, it was proved 
that it did not depend upon a faecal mass 
in the colon, it must lie either on or over 
the stomach and particularly on the lower 
border of the stomach. I decided that 
it depended upon a malignant neoplasm 
of the greater curvature of the stomach 
and probably of the omentum also. 
This tumor remains in the same position, 
it is larger, it is more superficial, it is 
more tender than it was, you can see it 
now as well as feel it. When he is lying 
down it is very apparent, running from 
the free border of the ribs in the left 
hypochondrium downward toward the 
umbilicus. 

The man has had great pain, from 
which he still suffers. The treatment 
consisted in the administration of mor- 
phine to relieve pain, and the giving of 
peptonized milk. You remember that 
we found a marked diminution of urea, 
there being not more than half the nor- 
mal quantity — a symptom which I con- 
sider of great importance in the diagnosis 
of malignant growths in the abdominal 



o. 3 



Lately, this man has developed oedema, 
and his legs are now bandaged to support 
them. You can see the lines of the 
bandage upon his calves. His right leg 
is worse than the left. He had no oedema 
at all when he first came here. I pre- 
sume he weighed twenty pounds more 
than he does now ; although he has had 
rest, he has not exercised, he has been 
fed all he could eat, and particularly of 
milk and predigested foods. CEdema is 
an important symptom always, and we 
must seek its cause carefully. When 
there is general oedema it usually shows 
over the sternum and ribs. I do not 
find it here. There is nothing in the 
heart to explain his oedema. At first 
thought you would say that his oedema 
was to be explained by his anaemia and 
by the disturbance of the blood from the 
carcinomatous disease from which he 
suffers, and that may be quite enough to 
account for it. General oedema and very 
marked anasarca are part of the typical 
history of the later stages of malignant 
disease. You know how apt it is to occur 
in the later stages of phthisis. No 
matter where the neoplasm exists, the 
waxy appearance of the skin and the 
oedema especially localized to the feet 
is part of the general cachexia. In this 
case it so happens that in addition to the 
cancers and its accompanying anaemia, 
there is something wrong with the 
kidneys. The urine contains albumen 
which has increased in quantity, the 
urine is loaded with casts and desquamated 
epithelium. The patient has a chronic, 
diffuse nephritis, due either to the malig- 
nant disease directly, or it may be of an 
entirely different nature. Its rapid in- 
crease, however, concomitant with that 
in the tumor of the abdomen, makes me 
think that there is malignant disease of 
at least one kidney. But we must not 
be carried away in our reasoning by any 
preconceived idea. As an illustration of 

(8i) 



MEDICAL AND SURGICAL 
REPORTER. 

1820. PHIIvADElvPHIA, JANUARY 16, 1892. Vol.. LXVI.— N 



82 



Clinical Lecture, 



Vol. Ixvi 



the errors into which preconceived ideas 
lead us, I might relate the anecdote of a 
professor in a Southern medical college, 
into whose clinic a man came whom he 
thought he recognized. The professor 
turned to his class and said : * ' Now, 
gentlemen, look at this man ; can you 
tell me what is the matter with him ? ' ' 
And, as no one replied, he continued, 
"He looks perfectly well to you, I 
suppose, but the moment I put my eyes 
on this man I knew he was a deaf mute ; 
he can neither hear nor speak. ' ' At this 
point the man spoke up and said : "I 
beg your pardon, boss, but it is my 
brother who is a deaf mute ; he sent me 
in to see if you were ready for him." 

It is very easy to get a preconceived 
idea about a case ; therefore, before 3^ou 
make up your mind that a patient has 
a certain condition you must demonstrate 
it without jumping at conclusions. I 
might very easily have explained this 
oedema to you on the ground of the 
blood dyscrasia due to the malignant 
disease, and we might have neglected his 
kidney lesion, but by carefully diagnos- 
ing and then attending to it, we may be 
able to prolong his life. 

I shall continue with the morphine to 
relieve this man's pain, the peptonized 
milk to support him. His bowels shall 
be kept open and his skin stimulated. 
There will be no medication directed 
especially against the Bright' s disease. 

DIAGNOSIS BY IvAVAGB. 

This patient has been under treatment 
for what has been supposed to be gastric 
ulcer. He is a woodsman, aged 45, who 
has been obliged to discontinue his work 
on account of vomiting, pain in the stom- 
ach, fermentation, with the formation of 
gas and intestinal indigestion in addition 
to the condition in the stomach. He has 
been on a milk diet, with salol and pan- 
creatine given after meals, the former to 
prevent fermentation, the latter to aid in 
the digestion of the milk. At present he 
is without pain, he has no vomiting and 
he feels very well. Without discussing 
in detail the reasons for the diagnosis of 
gastric ulcer, I would say that of late we 
have been led to reconsider the ques- 
tion. In the first place, 75 per cent, 
of all cases of gastric ulcer occur in 
women, and they general!}^ occur early 
in life, whereas this man is over 40. It 
is rare for an ulcer to occur in a man en- 
particularly in the morning, after break- 



fast, while in ulcer it occurs typically with 
equal frequency after every meal. If he 
gaged in hardy out-door work. Again, 
his vomiting has been noticed to occur 
would not empty his stomach by vomit- 
ing immediately he suffered pain. That 
is like gastric ulcer. The pain was rather 
localized, and at a point where the pain 
of gastric ulcer is usually felt, midway 
between the ensiform cartilage and the 
umbilicus, and a little to the right of the 
median line. There is local tenderness at 
this point also, but although I do not 
find a general tenderness, I can make out 
several tender points. The pain of gas- 
tric ulcer is usually made worse by eat- 
ing at any time, but, on close question- 
ing, I find that sometimes our patient can 
eat without any disturbance whatever. 
His vomiting, he says, has been sour, a 
symptom which is characteristic of gas- 
tric ulcer, in which, according to my ex- 
perience, there is always an excess of hy- 
drochloric acid. I must accept, however, 
the statement of other observers, who as- 
sert that ulcer is not alwaj'S accompanied 
with an excess of hydrochloric acid. The 
contents of his stomach have not been 
examined, for the presence of this acid 
and the sourness complained of may have 
been due to acids of fermentation, acetic, 
lactic, etc. 

This case is a little perplexing, and 
while strongly suggestive, it is not typi- 
cal of gastric ulcer. Let us see if it 
can be explained on another hypothesis. 
There is a neurosis of the stomach, char- 
acterized by the excessive secretion of 
hydrochloric acid and by gastralgia. I 
believe that gastric ulcer depends upon 
imperfect innervation of a certain part of 
the stomach in connection with the same 
acid neurosis, and that owing to the in- 
tensity of the hydrochloric acid and the 
stomach ferments, this portion of the 
stomach is digested. But there may be 
the same group of symptoms of gastral- 
gia, vomiting, localized tenderness and 
excess of h3^drochloric acid without the 
actual existence of the ulcer. When 
there is no ulcer, but simply the acid 
neurosis, there may be occasionally a 
meal taken without any pain whatever, 
and then the next meal will cause pain. 
Depending upon that one point, I might 
dismiss this as a case of gastric acid neu- 
rosis, but the diagnosis can only be made 
after careful study, and we must not go 
so fast, for men and women have died of 
gastric ulcer without having had pain, 



January i6, 1892. 



Clinical Lecture. 



83 



vomiting or any other recognized symp- 
tom, and yet the ulcer has been found 
post mortem. 

I propose, therefore, to empty this 
man's stomach through the tube and 
examine its contents, first, to see if there 
is an excess of hydrchloric acid ; second- 
ly, to ascertain the digestive strength. 
Three or four hours ago he had a meal of 
bread and butter, meat, egg, and some 
milk. The egg and milk I did not intend 
him to have. Now we ought to find the 
stomach contents a pulpy mass, showing 
the meat decolorized, the starch dissolved 
and hydrated ; the butter ought not to 
appear as distinct particles of floating 
fat, but the- capsules of the fat cells 
should have been broken up and the 
contents should have passed in large part 
into the intestine. 

Ordinarily, for the purpose of empty- 
ing the stomach, it is best to have a con- 
tinuous tube, for joints are apt to inter- 
rupt the outward flow of solid substances. 
It should be four or five feet long and an 
inch and a half in circumference. It should 
be flexible enough to be introduced into 
the oesophagus without causing damage, 
but not too soft. It should have two 
openings into the stomach, one at the 
end as large as the lumen of the tube, the 
other on the side, so as to render acciden- 
tal plugging of the tube less likely to 
happen, but this opening should be less 
than an inch from the end, as otherwise 
gas entering it from the stomach might 
spoil the siphonage. The stomach tube 
is usually passed twenty two (22) inches 
from the teeth. Sometimes, owing to di- 
latation of the stomach, it is necessary to 
insert the tube to a depth of from twenty - 
five to twent5^-eight inches, and the dis- 
tance depends somewhat on the height of 
of the body, but there is unusual uniform- 
ity in the rule that the tube acts best when 
passed to a depth of twenty- two inches. 

I will now introduce the tube, directing 
the patient to give most of his attention 
to taking long breaths, in order to dis- 
tract his attention from the tube. It is a 
good plan to have the patient vomit some 
of the gastric contents undiluted, but 
often, as in this case, it is necessary to 
put in a little hot water, so as to fill the 
siphon, and it is well to make sure that 
the water is not too hot. 

After some manipulation of the tube, 
I remove part of the stomach contents, 
showing lumps of undigested meat, oil 
floating on the surface of the fluid, and 



starchy food in masses. I see nothing in 
the way of milk or milk curd. The di- 
gestive strength of the stomach is below 
par, and as there is so much solid matter, 
we will abandon the attempt to empty 
the stomach and withdraw the tube. Ap- 
plying the phloro-glucin-vanillin test, 
there is a fair reaction to hydrochloric 
acid, but no excess. The chloride of iron 
and carbolic acid test shows the absence 
of lactic acid. 

Considering this man's age and occu- 
pation, the history of pain and vomiting, 
in the morning particularl}^, and not al- 
ways following meals, the absence of an 
excess of hydrochloric acid, the slowness 
in thel digestion of meat and albumen of 
all kinds, all of which things are contrary 
to the idea of gastric ulcer, it seems to 
me that this man has not that disease. 
Furthermore, he has not that form of 
neurosis of the acid type which I have 
described to you. He has a form of indi- 
gestion in which the ferments are not of 
sufficient strength, and he is lacking in 
the power to digest albumen. This we 
can prove by filtering part of the gastric 
contents and adding a small amount of 
egg albumen and noting the time neces- 
sary for digestion at the ordinary temper- 
ature. The time should be two or three 
hours, if it be five or six hours the stom- 
ach is weak, and if the egg remains for 
twenty-four hours without change, the 
peptic strength is practically nothing. 

The origin of this man's trouble was 
probably from taking too large amounts 
of food when he was tired and unable to 
digest it. The pain from which he has 
suffered is an ordinary gastralgia. How 
to account for the local tenderness I do 
not know, unless there has has been some 
local injury to the stomach by a hard 
fragment of bone which he has swallowed. 

I am inclined to think that by giving a 
milk diet, with long intervals between 
the meals, he will improve. The milk 
should be given digested, if necessary, 
either by peptonising it or by giving pan- 
creatine with it, as is now^ being done. If 
he had an excess of hydrochloric acid, 
either with or without ulcer, I would give 
frequent meals to keep the acid busy di- 
gesting food rather than acting on the 
stomach wall. The treatment of the acid 
condition by complete rest of the stomach 
and rectal nutrition may also be carried 
out, for if we give no food the acid will 
not be secreted. But one extreme or the 
other of treatment must be carried out. 



Communications. 



Vol. Ixvi 



ACUTE GASTRITIS. 

There is little in the history of this 
case that needs to be repeated. A man 
of forty- three, in good health, save that 
he had been drinking, and while some- 
what under the influence of alc©hol, he 
went into a barber shop and was there 
given to drink what purported to be bay- 
rum, but which was in fact a mixture of 
bay-rum and ammonia. How much of 
this he drank he does not know, but 
probably three or four ounces. He fell 
down and lost consciousness, and then 
the next thing he remembers is that he 
was in the hospital. He was treated at 
once by the accident hospital surgeons ; 
his stomach was emptied and he was 
given demulcents. He was brought here 
unconscious, but he very soon revived 
and the stomach was found to be acutely 
inflamed. This is an instance of a rather 
rare disease, according to my classifica- 
tion — acute gastritis. He had the usu- 
ally profound sj^mptoms, which subsided 
under treatment, but they were followed 
b}^ symptoms of sub-acute gastritis, which 
is very apt to follow the acute. The sub- 
acute gastritis was accompanied by such 
symptoms as vomiting, tenderness on 
pressure, general malaise, slight rise of 
temperature, a continued albuminuria, 
which was present during the acute gas- 
tritis, and wakefulness. The sub-acute 
gastritis might possibly have been, to a 
certain extent, due to the alcoholic habit. 
He has been drinking right along since 
Christmas, and probably his nervousness 
and vomiting have been due in part to 
that fact. He has made a good conva- 
lescence on demulcents and rectal nour- 
ishment till he was able to take food by 
the mouth, when he was given peptonized 
milk in small quantities. 

The symptoms of acute gastritis, pro- 
perly so called, are pain, tenderness, 
vomiting, and the vomit containing mucus 
and sometimes blood and shreds of mu- 
cous membrane, generally high fever, 
usually very marked cerebral disturb- 
ances and often albuminuria, sometimes 
casts and blood appearing in the urine as 
well as albumen ; sometimes haemorrhages 
and melsena or bloody discharges, show- 
ing the presence of changed blood in the 
stools. 

I am not going to quarrel with those 
writers who call what is described here as 
sub-acute gastritis, acute gastritis. It is 
simply a question of terms. But remem- 
ber, when you have an acute gastritis due 



to poisoning or the swallowing of hot 
fluids, you have a serious disease to deal 
with. That which is ordinarily called 
acute gastritis, I think is properly called 
sub-acute gastritis, since its symptoms are 
much milder. The treatment by demul- 
cents is very important. A person may 
be given oil when he is vomiting to make 
the vomiting easier and to help empty 
the stomach. Pure salad oil may be 
given ; after that mucilaginous drinks, 
like acacia water or slippery elm tea, or 
albumen in water should be administered 
until the stomach is quieted down. Then 
the patient should be given bismuth 
stirred in water, not the dry powder. It 
cannot be dissolved, but it can be sus- 
pended in mucilage water better than 
in clear water. It acts as a dressing to 
the inflamed mucous membrane. With 
the bismuth I think it is very useful to 
give cerium oxalate, and it is also advis- 
able to give such patients morphine 
hypodermically. 



COMMUNICATIONS. 



THE MEDICAIv TREATMENT OF APPEN- 
DICITIS, WITH A REPORT OF FIVE 
CASES ENDING IN RECOVERY.-:^ 

BY A. B KIRKPATRICK, M. D , 

PHILADEI<PHIA. 

The diagnosis, symptomatology, and 
pathology of diseases in the region of the 
caecum have been so recently and ably 
given by Drs. Price and Morton, members 
of the society, that it would be useless 
for me to go over the ground again and 
attempt to add anything new on the sub- 
ject. Surgery has made such marvellous 
advancement and accomplished such 
brilliant results in the last decade, that 
the medical treatment of certain diseases 
appears, at least for the time being, to be 
eclipsed. I am led to believe, from m}^ 
limited experience, that some of our 
younger surgeons are too ready to perform 
abdominal section before they have ex- 
hausted the medical armamentarium, 
which, though perhaps somewhat slower, 
may be surer and subject the patient to 
less risk. 

I think the surgeon in consultation 
with the physician will be able to deter- 
mine and select the cases for operation, if 
they are so fortunate as to see them in 

* Bead before the Philadelphia County Medical 
Society, December 9th, 1891. 



January i6, 1892. Communications. 



85 



their incipiency, but in many of these 
cases the physician is called in late, and 
the surgeon later — too late in some cases. 

We are all more or less infatuated with 
the wonderful results of present su^-gery, 
because, I think, it is something tangible. 
We make our diagnosis of appendicitis, 
open the abdomen and remove the dis- 
eased organ. There is the ocular proof 
of our skill in diagnosis and operation. 
In medical treatment our evidence, if we 
can produce any, is not so conclusive. It 
is of a more circumstantial character. 

No one of the same experience feels 
more deeply than I do the debt of grati- 
tude we owe to aggressive surgeons, and 
no one, I think, takes the knife with 
more satisfaction, but I must always be 
certain that it is the only or safest method 
for the patient. 

In the five cases that I wish to report, I 
demonstrated within twenty-four hours 
— in four of them at least— that an opera- 
tion w^as not necessary, and all the five 
recovered without section. You may 
infer that they were all mild or benign. 
Three of them were, because seen early 
and treated vigorously. 

Perhaps the title of my paper is not 
broad enough to cover it, but I wish to 
include in the medical treatment of typh- 
litis everything short of surgical opera- 
tions, for I rely as much, or more, on 
mechanical measures as on internal medi- 
cation. I wish to report what I consider 
as the most critical case first, though it 
was my third in regard to date. The first 
case dates from March, 1889. 

In four of the cases other physicians 
had been in attendance, or saw the patient 
with me in consultation. Two of the 
cases came to my notice late in the dis- 
ease, and to make the history complete, I 
shall be obliged to read parts of several 
letters which were kindly written to me 
by the physicians who first had the cases 
in charge. 

For the previous history of the first 
case, I am indebted to the kindness of 
Dr. Kdwin B. Wheeler, who wrote me 
the following letter two months after 
treating the case : 

" Was called to see Master A., thirteen years old, 
Thursday, April 2, 1890. He had been constipated 
a day or two, evidence conflicting as to the condi- 
tion of the bowels previous to that time. There 
had been no diarrhoea, however. I first thought it 
a case of typhoid fever, as the father had just 
recovered from that disease. I ordered a powder 
of calomel, but no action. Then gave one bottle of 
citrate of magnesia in half-bottle doses, with no 



result. The pain and tenderness in inguinal region 
increasing. Some tympanites. Gave injection of 
tepid, soapy water, with a few drops of turpentine 
without any result. On Friday I gave drachm 
doses of Rochelle salts in one-third of a glass of 
water every hour for four doses, and tincture of 
hyoscyamus. There was no result so far as any 
action of the bowels was ( oncerned. The vomiting 
was increasing and the tenderness covering a larger 
area. During this time it had become apparent 
that we had to deal with an obstructed bowel due 
either to intussusception typhlitis or perityphlitis. 

"Injections on Saturday morning were not re- 
tained. Passes up a catheter, but still injection 
was not retained. Gave morphine in small doses. 
Saturday p. m. Dr. J. H. Dripps saw the case 
with me We agreed as to the case, but were both 
on the fence as to the advisability of section. We 
then called in Dr. Noble, of the Kensington Hos- 
pital, Saturday, 6 p. m. After talking over the 
case, we concluded that the boy's best chance was to 
have the belly opened and the obstruction removed. 
We ordered a room cleaned and agreed to see the 
case the next day. 

"At 9 a. m., Sunday, April 6th, we (Drs. Dripps, 
Noble and myself) met and concluded that the boy's 
chance would be slight if we operated in such un- 
sanitary quarters, with such nursing as the father 
and mother could give. The parents agreeing, we 
wrote to the Pennsylvania Hospital, asking them to 
take the case, the father to let me know the result of 
his errand. We separated with the understanding 
that if the hospital refused to admit him, we would 
operate, Dr. Noble saying he would hold himself 
in readiness until 2 p. m. 

' About 11a. m., the father informed me that 
the hospital authorities would send for the case as 
soon as I desired. I sent him back to the hospital 
with word to send for the case immediately. Some- 
where about 8 p. m. the father informed me that 
he had been down town, but did not go to the hos- 
pital. He had stopped to see the boy's aunt, who 
said he should not go to the hospital. Whereupon 
I dismissed the case, refusing to have anything 
further to do with it. The case has certainly re- 
sulted very fortunately in your hands, and 1 am 
truly pleased, etc." 

I will not go fully into the diagnosis of 
this case, for I was perfectly satisfied 
when I learned from the father who had 
consulted in the case. 

"I was called in to the case at 10 p. m., Sunday, 
April 6th. The symptoms all indicated complete 
obstruction of the bowel and collapse. He had 
vomited first on Wednesday. The temperature 
was 96|° ; pulse indistinct at wrist ; heart was 140 
per minute, and he was in a cold perspiration ; 
respiration 40. Abdomen exceedingly tympanitic 
and bladder much distended. There was stercora- 
ceous vomiting, and nothing had been kept on the 
stomach for days. I at once gave a hypodermic of 
morphine, atropine and strychnine, and then 
emptied the bladder by a catheter, and about six- 
teen ounces of water passed. The patient was 
apparently moribund, but revived somewhat after 
the hypodermic injection, and though I feared he 
would die while giving it, but I knew there was 
nothing to lose and thought there might be a slight 
chance for life if the obstruction could be removed, 
so I had him supported in the knee chest position 
and injected a pint of warm liquid containing 



86 



Communications. 



Vol. Ixvi 



castor oil, turpentine, whiskey and Epsom salts. 
This was about 11 p.m. 

This was kept in the bowel for half an hour by 
a compress, held in position by the hand, then he 
was allowed to lie down on the right side. Within 
an hour there was copious evacuation of liquid 
with scybalous masses The injection was repeated 
at 12 o'clock, and another free movement resulted. 
These greatly relieved the tympany and pain. We 
then began to give turpentine and whiskey by the 
mouth once in two hours, and also a drachm of 
Epsom salts in hot water once in two hours alter- 
nately. Only the first dose of salts was rejected. 
The whiskey and turpentine were retained. These 
were regularly administered through the night I 
left the patient at 1 a. m. asleep, and he had 
become much more comfortable. 

" On returning in the morning, I found there 
had been several more movements, and the bladder 
had been emptied naturally. The tumor over 
the right iliac fossa had nearly disappeared, and 
the pain and tenderness were much less. The 
temperature was normal. The tongue and sordes 
on teeth indicated typhoid fever. There were five 
movements of the bowels within twenty-four hours 
after the enema, and not less than three to six any 
day after for two weeks. The temperature gradu- 
ally rose to 102°, and the evening temperature was 
about that for a week, when it gradually declined, 
but did not become normal till the "iQth, or three 
weeks from the time 1 first saw the case. The 
stools had quite the appearance of typhoid, as did 
the tongue, and there was a suspicious eruption on 
ihe chest and abdomen. After the obstruction was 
removed the case was treated as a simple case of 
typhoid fever. He had two grains of quinine and 
one-thirtieth of a grain of strychnine three times a 
day, with nitro-muriatic acid, pepsin and bismuth 
every four hours, and paregoric when needtd to 
control the bowels, and a liquid diet throughout. 

"At noon, the fourteenth day after I first saw 
him, after some pain and flatus, he passed a slough 
from the bowel, which, in the recent state, was 
elliptical and two and a half inches the long diam- 
eter. There seemed to be some pain and tendency 
to collapse, so he got another hypodermic and free 
stimulation. There was also a rise of 2° in tem- 
perature. He rallied the next day, and made a 
rapid and complete recovery, 

" On May 6th, which was just a month from the 
time I first saw him, he sat up and took solid food. 

"He is a strong, healtny boy and now drives 
for me." 

I watched the case very closely through- 
out, and feel certain that the intussuscep- 
tion, or typhlitis, or perityphlitis, was 
followed by a clear case of typhoid fever. 
I am by no means so clear in regard to 
the pathological condition in the region 
of the caecum and &hall greatly appre- 
ciate the views of the members of the 
society on that point. 

"The second case, Mr. M. K., who is a pronunent 
and very active literary man in this city, dates 
from March 24, 1889. 

The patient gave me a very intelligent historv 
of his case, which was that there had been a gradual 
decrease in the evacuations for several weeks, with 
a great deal of distention and discomfort of abdo- 
men, and finally obstinate constipation followed. 



When I first saw him there had been no movement 
for several days. 

" He had a tumor and localized pain in the right 
iliac fossa. Temperature 103|°. Pulse 120. Coaled 
tongue, etc. 

" He was given a hypodermic of morphine and 
atropine for the pain, which gra lually spread over 
the abdomen as the gas accumulated. Two large 
doses of castor oil and turpentine were taken with- 
out any action. He took calomel, soda and ipecac 
powders for twelve hours, followed by Hunyadi 
water, but still there was no movement of the 
bowels. We then resorted to the enemata of tur- 
pentine, laudanum, castor oil, Epsom salts, and hot 
water, given in the knee-chest position. These 
moved the bowels freely and relieved the pain and 
distention. Turpentine stupes were also used freely. 

"There was a double inguinal hernia in this 
case, and to satisfy ourselves that there was no 
strangulation of the gut. Dr. W. W. Keen was 
called in consultation, and pronounced the case free 
from any such complication and confirmed the 
diagnosis of appendicitis. He suggested pills of 
colocynth comp. and opium. 

" The patient made a good recovery, and for 
several weeks took pills of aloin, strychnine, bella- 
donna, cascara and physostigma to relieve the 
atonic condition of the bowel, and an occasional 
dose of Hunyadi, as he was rather stout and full- 
blooded. 

*' In July, or four months later, this same patient 
had a recurrence of the trouble while at the sea- 
shore, which began, possibly, with a slight tendency 
to constipation early, but the first the patient com- 
plained of was a severe serous diarrha?a with high 
temperature — 104°. Pulse 128 (normal 58). Severe 
pain in the ileo-csecal region. This attack began 
before I took up my summer practice at Cape May 
Point, and Dr. F. E. Stewart, of Wilmington, was 
called in. 

" He made the diagnosis of colliquative diarrhoea, 
and gave acetate of copper and morphine to check 
it, and aconite for the fever, but nothing seemed to 
have any permanent control over the bowels. 

Right here in this ca^e, which was my 
first patient, but his second attack of 
appendicitis, I learned a very valuable 
lesson. Here was an obstructed bowel, 
and nature was trying, by pouring out a 
verj^ excessive liquid secretion, to flush 
out the obstruction or foreign matter. 

I simply took the cue from nature, and 
with srnall, frequently repeated doses of 
calomel, ipecac and soda, followed b}^ 
salines, accomplished the object, and in 
less than six hours had the satisfaction of 
seeing the tumor, which had been in the 
region of the caecum, deposited in a com- 
mode, which the black, ver}^ offensive 
mass nearly filled. In this attack we 
used hypodermic injections of morphine 
for pain, and pilocarpine for the high 
fever and dry skin and tendency of 
cerebral congestion, as the kidneys were 
not acting at all freely. There was no 
vomiting after the first hypodermic, and 
the patient began at once to take iced 



January i6, 1892. 



Communications . 



87 



champagne and ApoUinaris, and soon 
was able to take milk and other liquid 
food. 

In this case no resort was had to rectal 
enemata, as the bowels were thoroughly 
cleared out within six hours after the time 
I first saw the patient, and in three or 
four daj^s he was attending to his regular 
business. He took the aperient, tonic 
pills for several months, and was re- 
quested to use Hunyadi water freely, and 
rectal injections, if the symptoms oc- 
curred again. He has had no recurrent 
attacks and no constipation since. 

The fourth case, MissS., occurred at 
Cape May Point, and was first seen and 
treated by Dr. F. B. Stewart, Wednes- 
day, August 25, 1891. I wished to speak 
of this case at the special meeting, Sep- 
tember 28th, when Dr. Morton read his 
interesting paper on ' ' The Surgical 
Treatment of Appendicitis," and wired 
Dr. Stewart for his diagnosis, and he sent 
me the following telegram: " Case was 
obscure. Called Dr. David Stewart in 
consultation. He said 'appendicitis.'" 
I am indebted to Dr. F. K. Stewart for 
kindl}^ furnishing me the historj^ of this 
case, which I quote from his letter : 

" In the case of Miss S., there were pain and ten- 
derness over the abdomen, which, as the case 
developed, became marked in or over the right 
iliac fossa. Instead of dorsal decubitus, the patient 
sat in a chair with her thighs flexed on the abdomen, 
and could not lie down until relieved by treatment. 
There was fever; temperature 102°. There was 
constipation, nausea, and, if I remember correctly, 
some vomiting, but the latter was not a marked 
symptom of the case. I did not discover a tumor 
on abdominal palpation or vaginal touch, but Dr. 
David Stewart, who saw the case with me on the 
second day, called my attention to what appeared 
to be a doughy mass on the right side of the body 
on examination -per rectum. 1 must confess that I 
would not have discovered said mass except my 
attention had been called particularly to it, or, in 
other words, I might have had a suspicion of its 
existence, but it required a finger of more educa- 
tion than mine in feeling for tumors of this nature 
to make a positive diagnosis. 

"The treatment suggested consisted of hot tur- 
pentine stupes, opium and iodide of mercury. 
Under this she seemed to improve. 

" From the beginning I recognized the gravity 
of the case. I advised her to go to the city at once, 
as proper nursing was out of the question, situated 
as she was at the Point. Furthermore, I told her 
if she got worse an operation might become neces- 
sary, and then it would be too late to remove her. 

" I first saw the case on Monday, August 31st, at 
6.30 p. m., and found her extremely weak and ner- 
vous from the trip from Cape May Point. The tem- 
perature was 103j°, pulse 120, abdomen tense, tym- 
panitic and extremely sensitive. I found a large 
tumor in the region of the ileo-csecal valve, intense 
pain and nausea. There was extreme tenderness 



over the tumor and abdomen generally, indicating 
a good deal of general peritonitis. 

" Miss S. was brought to the city by her sister- 
in-law, and they went into a house where the furni- 
ture had just been piled in. There was not even 
a bed up or any convenience for heating water, so 
in regard to nursing and environment she did not 
improve her condition. When I arrived she was 
on a bed that had been hastily put up. 

"The sister-in law, who acted as nurse, got hot 
water for stupe and enema, and the patient had the 
same treatment, practically, as the boy — the first 
case reported — except that the nurse gave the ene- 
mata, who proved very intelligent and efiicient. 

"When I called next morning, I found the 
bowels had moved freely several times, and though 
the patient had had a restless night, she had slept 
some. The pain and distention were nearly gone 
and the temperature had fallen to 101°. By 
Wednesday, September 2d, the temperature was 
normal and the pain was entirely gone. She began 
sitting up Thursday, without my knowledge, and the 
next Wednesday she went back to the Point. I 
believe she had a slight recurrence of the pain, 
inflammation and constipation the week after she 
got home, but they were controlled by injections, 
stupes and opium suppositories. 

"She has enjoyed good health since." 

The other two cases of typhlitis, which 
occurred in my practice within the last 
year, were quite similar in regard to 
symptoms and treatment to the others 
that I have reported in detail, and as I 
relied only on m3^self for the diagnosis 
and treatment, I will not weary you with 
a repetition of them. I have not aimed 
to give the latest and most approved 
treatment from the text- books of the day, 
but what seemed to me to be indicated 
and necessary in the emergencies of these 
cases, when I dared not waste a moment 
in temporizing or experimenting. It ap- 
pears to me a serious loss of time to de- 
pend solely on external applications to 
the abdomen and protiodide of mercury 
with belladonna and opium internally, 
when we have to deal with a bowel ob- 
structed by hardened accumulation of 
faeces. I believe most cases of obstruction 
of the bowel, if not due to intussuscep- 
tion or strangulated hernia, are due to the 
absence of the natural secretion caused 
by the localized typhlitis, which, if not 
soon relieved, becomes a perityphlitis, 
and then more or less general peritonitis 
must result. The rational method seems 
to me to be : ( i ) To relieve the pain by 
hypodermic injections. (2) To remove 
the cause or obstruction by causing, if 
necessary, pathological or excessive secre- 
tion, by giving some saline, which I be- 
lieve is the best antiphlogistic for the 
inflamed bowel. (3) To soften the har- 
dened faecal accumulation from below with 



88 



Commun ications. 



Vol. Ixvi 



enemata, solution of Epsom salts in water 
as hot as can be comfortably borne, to 
which I add turpentine and oil. The 
knee-chest position, with copious enema, 
favors the distention of the colon up to 
the seat of the disease. 

I have found by experience that the 
enema to be effective must be given in 
this position, and that it must remain in 
the bowel for some time, and in several 
of my cases it was necessary to repeat 
the operation three or four times. This 
plan of treatment has been successful in 
six cases, which are all that I have 
treated ; but I fully realize that it may 
fail in the seventh. 

I think it is truly in meetings like this 
that surgeons are broadened medically 
and physicians surgically — if I may be 
allowed the phrase. Doctors are only 
human, as we hear it said of ministers, 
and as such they are prone to do what 
they prefer, whether it be surgical or 
medical, and naturally they do best what 
they like to do and do oftenest. — For dis- 
cussio7i^ see Society Reports. 



ABSCESS OF THE ANTERIOR VAGINAL 
WALIv." 

HENRY R. SMITH, M. D., 

DKTROIT, Te:xAS. 

I was consulted August ii, 1 891, by 

Mrs. G. , aged twenty-one, married 

two years. She has never been preg- 
nant, looks swarthy, is weak and gets 
easily out of breath. She dates her pres- 
ent trouble back six years. First men- 
struated at twelve years of age ; has not 
menstruated during the past four years ; 
has constant pain in the lower part of the 
abdomen ; has to get up three or four 
times during the night to urinate. She 
has a leucorrhoea and some pus from the 
vagina; temperature 101°; pulse weak, 
and has not been able to do her house- 
work for some time past. 

On digital examination I find a tumor- 
like bod}^ situated in the anterior vaginal 
wall, just inside the vulva, the size of an 
orange, hard to the touch, and no fluctu- 
ation. The exploring needle reveals 
pus. A free incision was made into the 
tumor, and a pint and a half of foul- 
smelling pus evacuated. The cavity, 
which measured four inches, was thor- 

* Kead before the North Texas Medical Associa- 
tion, December, 1891. 



oughly curetted, and then irrigated with 
bichloride of mercury solution 1-2000, 
and also peroxide of hydrogen. The 
patient was seen three days later ; some 
pus escaping. A drainage tube was intro- 
duced, and the cavity ordered to be 
washed out twice daily with bichloride 
solution. No fever. 

On the tenth day after operation, 
patient was doing w^ell. No cystitis ; 
patient sleeps well at night; treatment 
continued. 

Fifteenth day, menses returned, and 
not painful. Drainage tube removed, and 
cavity injected with tincture iodine. 
Twenty-first day, some pus discharging ; 
drainage tube re-introduced ; cavity 
ordered to be washed out twice daily with 
bichloride solution. Patient looks well ; 
has gained twelve pounds in weight. 
Thirty- first day, no pus ; drainage tube 
removed, and cavity injected with nitrate 
of silver. 

Sixth week, there was no discharge ; 
menses regular and not painful ; no 
cystitis; abscess cavity retracted. Patient 
is now doing the cooking for twelve 
cotton pickers, and considers herself well. 
Case discharged. 

I wish to say, in conclusion, that Mrs. 

G. has been taking medicine from 

doctors and using patent medicines for 
the past six years. The lower part of 
her abdomen is a solid scar from 
blisters. 



THE SIMPIvE EXTRACTION OF 
CATARACT.^ 



EDWARD JACKSON, M. D., 

PROFESSOR OF DISEASES OF THE EYE IN 
THE PHII.ADEI.PHIA POLYCLINIC 
AND SURGEON TO WILLS 
EYE HOSPITAL. 



The old flap operation for the extrac- 
tion of cataract, when it was successful, 
was one of the brilliant triumphs of 
operative surgery. The trouble with it 
in the old time, before the day of Graefe, 
was, that it was successful in only a 
minority of cases. The real achieve- 
ment of the last few years with reference 
to it has been the increasing of the per- 
centage and the perfection of its suc- 
cesses, until they have surpassed any- 
thing achieved by other operations for 
cataract extraction. This has been 



*Read before the Philadelphia County Medical 
Society, October 28th, 1891. 



January i6, 1892. 



CommMfiica Hons. 



89 



brought about by collateral advances in 
medicine and surgery, that have given 
us an understanding of sepsis and asepsis, 
of the myotic power of eserine and its 
allies, and of the anaesthetic and other 
powers of cocaine. 

My purpose in this paper is to discuss 
the operation of ' ' simple extraction ' ' as 
I practice it, with the reasons for choos- 
ing certain procedures rather than others, 
and some comparison of the results of 
the method with modified linear extrac- 
tion, or modified Graefe method, which 
it has largely replaced. I used the term 
"simple extraction," because it is one 
commonly employed to designate the 
operation in question, and not to give the 
idea that cataract extraction was at all a 
minor or trifling operation. I think 
though that the term is strictly applic- 
able, for the operation is distinctly 
simplified in certain directions. And in 
that it is more simple it conforms with 
the general tendency of surgical advance 
at the present time, which is toward the 
omission of various procedures that were 
formerly believed necessary, and the con- 
centration of our attention on what is 
really essential, that it may be done in 
the best possible manner. 

The corneal section is made upward, 
mainly because it seems to me that the 
wound in this position is much better 
protected beneath the closed lids from 
either infection or the relative displace- 
ment of its lips than the downward sec- 
tion can be. It is made in the clear 
cornea, sometimes as close as it can be to 
the limbus without encroaching on it. 
It is parallel to the corneal margin, the 
plane of the knife making it being 
parallel to the plane of the periphery of 
the iris. It is made to include nearly, 
and sometimes quite, half of the circum- 
ference of the circle of which it is a part. 
The exact position of the section and its 
length are determined by the size of the 
cornea and the supposed size of the lens. 
The plane of the section should be well 
in front of the iris, for the risk of prolapse 
of the iris is thereby greatly lessened, 
yet the incision must be long enough to 
permit the escape of the lens. The sec- 
tion is made with the knife described by 
me in the A77terican Joumal of the Medi- 
cal Sciences for March, 1888, for the 
reasons there given, that it combines to 
to a large extent the manageableness of 
the Graefe knife with the smooth incision 
of the Beers knife. Usually the incision 



is almost completed by the forward thrust 
the cutting edge being carried by it out 
of the anterior chamber, and the remain- 
ing bridge of corneal tissue severed as 
the knife is withdrawn. 

The capsulotomy is made with the point 
of the knife used in making the corneal 
section, and is about in the plane of the 
corneal section, as the lens lies against 
the cornea after the escape of the aqueous, 
I have in a few^ cases opened the capsule 
before completing the corneal section, as 
the point of the knife was carried across 
from the puncture to the counter-punc- 
ture. This was done in the fear that 
after the escape of the aqueous the pupil 
would contract so that it would be diffi- 
cult or impossible to make a sufficient 
laceration of the capsule without wound- 
ing the iris with the knife-point. Such 
a manoeuvre, however, required a slight 
change in the direction of movement, 
and prolonged a little one of the most 
critical periods of the operation. It was 
given up on finding that a sufficient 
opening in the capsule can always be 
made through the pupil after the com- 
pletion of the corneal section. The 
opening that is necessary to make in the 
capsule is really quite small, a slit 4 or 5 
mm. long is quite sufficient, probably 
because, when the solution in the con- 
tinuity of the capsule is once started it 
extends quite readily, as widely as it is 
needed, under the pressure of the lens 
during the stage of its delivery. 

The advantages of the method of open- 
ing the capsule are that by it we get rid 
of one instrument, the cystotome — an in- 
strument hard to keep clean at the 
shoulder from which the pricking point 
projects, hard to get and keep perfectly 
sharp, liable from its shape to catch and 
damage the cornea or iris in case of sud- 
den movement while it is in the eye, and 
which I have seen more than once, by its 
direct backward pressure, dislocate the 
lens and allow the escape of vitreous. 
Then the small opening in the capsule 
nearly in the direction of the corneal sec- 
tion seems to have a decided influence in 
making sure of the proper rotation and pre- 
sentation of the lens in the corneal wound ; 
and cortical matter as well as nucleus has 
a perfectly direct avenue of escape ; and 
if cortical matter remains after the nucleus 
has been extracted, it remains inside the 
capsule, and not in the anterior chamber 
where it would exert its well-known dele- 
terious influence on the iris ; or, as some 



90 



Communications, 



Vol. Ixvi 



have supposed, furnish an especially fa- 
vorable culture medium for the pathogenic 
bacteria introduced on the shank of the 
cystotome or along a path of capsule in- 
carcerated in the corneal wound. Again, 
with this method of opening it, there is no 
chance that portions of the capsule will 
prolapse or become incarcerated in the 
wound, and so complicate the healing 
and endanger the ultimate result more 
insidiously, but quite as seriously, as pro- 
lapse or incarceration of the iris. 

This method of opening the capsule 
has this disadvantage, that when the 
pupil contracts, as it does in the process 
of washing out the anterior chamber, the 
iris sometimes entirely covers up the rent 
in the capsule and makes it much more dif- 
ficult to dislodge any remaining cortical 
matter. Under these circumstances, it is 
best to make no effort to dislodge it, for, 
in my experience, cortical matter left 
within the capsule after the removal of the 
lens nucleus is innocuous, and is certain 
to be removed by absorption in a few 
weeks at the farthest, causing some de- 
lay in the full restoration of vision and 
detracting from the brilliancy of the opera- 
tion, but in the end giving the patient the 
best result. 

The delivery of the lens is effected by 
making pressure with a lens spoon back- 
ward on the lower portion of the cornea, 
and with a corneal spatula slightly down- 
ward upon the upper ciliary region, caus- 
ing the lens to push into the pupil and 
engage in the corneal wound, the move- 
ment of the lens being steadily followed 
by a slight upward movement of the 
spoon, and the necessary pressure never 
relaxed until the greatest thickness of the 
lens has passed through the corneal sec- 
tion. It is of the utmost importance that 
the pressure be maintained steadily ; any 
intermitting of it that causes the lens to 
alternately advance and retreat is liable 
to bring about the displacement of the 
lens, and the presentation of the vitreous 
in its stead. After the nucleus has 
escaped, the pressure is gently continued 
until any evident masses of cortex have 
also been extruded, and then withdrawn. 

Washing out of the a^iterior chamber I 
have practised after the method and with 
the apparatus of Dr. Lippincott, of Pitts- 
burg, for the last year, as the principal 
step in the operative toilet. If the iris 
has prolapsed, the stream of boric acid 
solution is the simplest and best repositor, 
its effect being to carry the iris into posi- 



tion, and at the same time to provoke a 
marked and very satisfactory contraction, 
of the pupil. If the opening in the cap- 
sule remains freely accessible, the current 
may be directed into it and all lenticular 
debris removed. But if this is not readily 
accomplished, I content myself with a 
thorough washing out of the anterior 
chamber, at the end of w^hich the pupil 
is found small and central, stroking of the 
iris with the spatula, or poking into the 
angles of the cornea wound to dislodge 
incarcerated iris or capsule, being thus 
dispensed with. 

Eserine is instilled after the washing of 
the conjunctival sac, although the effect 
of the irrigation of the anterior chamber 
has been to already secure a small central 
pupil, in order that this contraction of 
the pupil may be maintained and the iris 
drawn as far as possible away from the 
cornea. In a single case in which I 
omitted the use of eserine a slight pro- 
lapse of the iris appeared at the end of 
thirty-six hours. Eserine was then used, 
and the prolapse promptly reduced. 
Later, however, it again appeared, and 
the pupil was left somewhat distorted. 

Simplicity. As compared with the 
Graefe method and its modifications, 
"simple extraction" deserves its name, 
in that the iridectomy that it dispenses 
with is the most painful and one of the most 
delicate portions of the former operation, 
and that the uninjured iris is more 
readily reduced and kept wholly within 
the eye than the iris that has lost the 
tensile action of its sphincter. It pre- 
vents the extremely insidious accident of 
incarceration of the capsule. Again, 
the dangers of that serious complication, 
prolapse of the vitreous, are reduced to 
a minimum. Without rough handling, 
or especially unfortunate movement of 
the eyeball, it is scarcely possible for this 
accident to occur before the nucleus is 
delivered. ' Even in a case of dislocated 
lens with fluid vitreous the delivery of 
the lens was readily effected without the 
use of a spoon or loop, and no vitreous was 
seen until this had been accomplished. 

Ease. The statement is usually made 
that with simple extraction the deliver}^ 
of the lens is slightly more difiicult. 
But, in my experience, this is true only 
to a slight extent as to the complete re- 
moval of the cortical matter. The delivery 
of the nucleus is not to any notable 
extent more difficult. I operated yester- 
day on a case where the lens were par- 



January i6, 1892. 



Communications. 



91 



ticularl}^ large and the cornea small. 
From the other eye, in which the condi- 
tions were precisel}^ similar, I had re- 
moved the lens several months ago, after 
a preliminary iridectom3\ with a good 
deal of difficulty. The simple extraction 
was, if anj^thing, the easier one. After 
the first operation a considerable amount 
of cortex remained in the capsule, and the 
same thing occurred with the second. 
Still, the removal of all remaining cortex 
is, I believe, a little more difficult after 
the simple extraction, though certainl}^ 
not more dangerous. 

Prolapse of the iris. The danger of this 
complication is the greatest drawback on 
simple extraction — about all that keeps 
it from being an ideal operation. When 
an3^ considerable prolapse occurs it causes 
a distorted pupil, is liable to delay the 
healing, is followed by unusually high 
astigmatism, and, if very large, might 
endanger the ej^e. The impression is 
abroad that it is very much more likel}^ 
to happen after simple extraction than 
after extraction with iridectomj^, at least, 
it is scarcely counted as one of the risks 
of the latter operation. But iridectomy 
does not prevent the occurrence, except 
of the part of iris that has been removed. 
Indeed, in so far as it removes the re- 
straining influence of the iris sphincter 
and leaves angles of iris floating within 
the e^^e, iridectomj^ directly favors incar- 
ceration, the form that prolapse assumes 
after it. Knapp has recently reported 
statistics of about five hundred cases of 
simple extraction, with prolapse of the 
iris in eight percent, of the cases. It is 
probable that incarceration of a part of 
the iris at the angles of the wound is 
ab.out that common among Graefe's ex- 
tractions. In my owm work prolapse has 
not been more common after simple ex- 
traction than w^as incarceration after 
iridectomy. More than this, the great 
mass of cases of prolapse under the use 
of eserine flatten down and cause as little 
trouble as the incarcerations after iridec- 
tomy, and do this without excision or 
any other special treatment, without 
notably delaying the healing, and, so far 
as can be judged, without any additional 
ultimate danger to the eye. I speak 
thus particularly about prolapse of the 
iris, for it was fear of it that kept me for 
a considerable time from giving up 
iridectomy. Still prolapse of the iris is 
the chief danger of the method and it 
should be carefully guarded against by 



the use of eserine, by keeping the patient 
as quiet as possible, by avoiding any 
pressure of the dressing or through the 
dressing on the globe, and by placing the 
corneal section as far away from the iris 
as possible, compatible with making it 
large enough to permit the escape of 
the lens. 

Visual acuteness. The principal advan- 
tage of the simple operation is the ex- 
clusion from the eye of a large amount 
of very imperfectly focussed light, and 
the retention of the power of adapting 
the eye promptly and fully to the varying 
intensity of the light to which it is ex- 
posed. This advantage, although shown 
partly by statistics of visual acuteness, 
can never be fully exhibited in that wa3^ 
An eye may be able to decipher even the 
smaller test-types, although their image 
on the retina is engulfed in a flood of 
unfocussed light coming in through dis- 
torted portions of the cornea opposite the 
coloboma left by an iridectomy. But 
even w4th only the abilit}' to make out 
the same type, the vision secured by the 
exclusion of this useless and confusing 
excess of light is for all practical purposes 
far superior. 

Again we find in age the retina 
habituall}^ guarded against even the light 
admitted to the 3^ounger normal eye b}^ a 
diminished pupil ; and the reversal of 
this, the flooding of the senile eye, with 
its slower nutritive processes, with an 
amount of light largely in excess of what 
it has been accustomed to, especially the 
crippling of its power to defend itself 
against sudden increase of illumination 
cannot but diminish its power of resist- 
ance to unfavorable influences, and lead 
to ultimate deterioration of vision. 

It was watching the gradual deteriora- 
tion that occurred in certain eyes that 
had been subjected to extraction, with 
iridectomy, that first made me desirous 
of trying the simple method. 

Indications for iridectomy. I am not 
aware of any operator who proposes the 
abandonment of iridectomy in all cases. 
It is pretty certain that in at least one 
class of cases all will continue to practice 
it, nameh^ those in which from iritic adhe- 
sions or from other causes the pupil is ex- 
tremely rigid and undilatable. The other 
indications for it are not so well agreed 
upon, but probably one of the most im- 
portant of them is extreme restlessness 
and insubordination on the part of the 
patient. All of my cases of prolapse 



92 



Communications. 



Vol. Ixvi 



have been in patients markedly of that 
character. For the present most of us 
will be apt to fall back on iridectomy for 
a number of reasons, as I did in a case 
about a week ago where there was 
reason to suspect a large lens and sac- 
charine diabetes, so that I feared slough- 
ing from a large corneal flap. But with 
myself, as with many others, the present 
tendency is to do iridectomy less and less 
frequently, audit is probable that the cases 
in which it is either necessary or desirable 
will ultimately be found to be few and 
far between. 



KIDNBY DISEASE WITH CARDIAC COM- 
PIvICATlONS, WITH EXHIBITION 
OF SPECIMENS.* 

JOSEPH M. PATTON, M.D., 
CHICAGO, ir.1.. 

The patient, male, was 40 years old. 
He had been living in a Western city for 
eight or ten years, and his family during 
this period had had no track or knew 
anything about him until he came to this 
city in the care of an escort, coming from 
Ogden. He told me he has suffered at 
various times during the past three or 
four years from what is termed in the 
Western country ' ' mountain fever, ' ' and 
that he had had a great deal of trouble 
with his liver. He had worked at print- 
ing, being a foreman in some large print- 
ing establishment, leaving that and going 
out into the open air and doing all kinds 
of hard work in the endeavor to stimulate 
himself to a better physical condition, and 
finally, after being told by his physicians 
that he had Bright' s disease, and would 
live but a short time, he accepted their 
advice and returned to Chicago. The 
man who came with him did not expect 
him to live until he reached Chicago, I 
saw him twelve hours after his arrival 
and found him sitting in a chair suffering 
from violent dyspnoea, unable either to 
lie down, to stand or walk. The lower 
portion of the lungs oedematous ; the 
lower extremities were swollen until the 
skin over the tibialis anticus in the left 
limb had bursted and was running freely 
with water. The liver was greatly en- 
larged from passive congestion until it 
filled three quarters of the abdominal 
cavity ; his stomach was somewhat con- 
gested, and he was suffering a good deal 



*Eead before Chicago Pathological Society, Octo- 
ber, 1892. 



of distress in this organ. He had no 
temperature ; his pulse was rapid and ir- 
regular; the heart was in a very arhythmic 
condition, but was beating with a good 
deal of force, which was not at all com- 
mensurate with the condition of the cir- 
culation in the arterial tract. Examina- 
tion of the heart revealed a very much 
enlarged condition of the organ, which 
was due partly to hypertrophy, and more 
so to dilatation of the left ventricle, the 
line of dulness extending two inches to 
the left of the nipple and down to the 
seventh intercostal space. No murmurs 
to be heard at the aortic valve. Of course, 
it would be a question in a condition of 
this kind as to whether or not a mitral 
regurgitant murmur would be present. 
Owing to such an extensive dilatation of 
the left ventricular cavity, you might 
have a mitral regurgitant murmur which 
would escape detection. The patient im- 
proved in the course of a week under 
treatment, which was, infusion of digi- 
talis, morphine and nitroglycerine with 
diuretics, the nitroglycerine with digitalis 
to counteract the tendency of digitalis to 
contract the arterial vessels, and thus re- 
lieve the distressing condition that might 
be caused in this way. There was little 
effect on the kidneys by this treatment. 
He was passing about four or five ounces 
of urine every twenty-four hours ; specific 
gravity, about 1023, heavily loaded with 
albumen ; few epithelia from the bladder 
and pelvis of the kidney, but no casts. 
He was given calomel according to the 
method of German physicians, when ad- 
ministering it as a diuretic in cardiac 
diseases, that is, giving three grains three 
times a day until six doses are taken, then 
wait. This was taken in this way, and 
at the end of the second day the kidneys 
began to act freely, and after the third or 
fourth day he passed four quarts of urine 
in twenty- four hours. Inside of four days 
the oedema was out of the lungs ; the 
liver had assumed its natural proportion, 
swelling of extremities disappeared, and 
the patient was feeling comfortable. 
Treatment directed toward his heart, and 
to improve his general condition, was 
continued. He did not gain in strength, 
and had periodical relapses into his for- 
mer condition, with return of the oedema 
of the extremities, enlargement of the 
liver and extension of the dilatation of 
the heart, with scanty secretion of urine. 
These attacks were preceded by distress 
in the stomach and symptoms of biliary 



January i6, 1892. 



Communications. 



93 



colic ; they were relieved only by the ad- 
ministration of the calomel. These 
attacks were preceded by marked arhyth- 
mia of the heart and accompanied also by 
marked Cheyne-Stokes respiration. Dur- 
ing the early part of m}^ attendance he 
was seen by Dr. J. D. Skeer in consulta- 
tion, who suggested contracted kidney as 
the cause of the cardiac condition, and 
while disease of the kidne3's was the onl}^ 
reasonable explanation, the efficient action 
of these organs obtained under treatment, 
made it rather uncertain. He suffered 
three or four relapses, and was under 
treatment nine months, and finally died 
from failure of the right ventricle, there 
being non-s)mchronous contraction of the 
ventricles prior to death, and at the time 
of death there was very little oedema, 
only such as one would naturalh- expect. 
The kidneys were acting fairly well until 
two days prior to death, when they gradu- 
ally ceased their action as would be 
expected from a failing heart. The 
Che3'ne-Stokes breathing was only 
present during the attacks above alluded 
to, and was not present for three weeks 
prior to death. 

The autops}^ was made with the assis- 
tance of Drs. J. D. Skeer and Geo. H. 
Cleveland sixteen hours after death, and 
showed that the body was fairl}^ well 
nourished. 

A 7dopsy sixteen hours after death: Bod}^ 
fairl}^ well nourished, rigor mortis not 
well marked. There was no fluid in the 
pericardial sac, the left pleural cavit}^ 
contained about a quart of clear fluid, the 
right pleural cavity was empty. A firm 
band of old adhesions about two inches 
wide connected the chest wall and middle 
of right lung. The lungs were much 
congested, and the seat of brown indura- 
tion almost black in places, very firm and 
indurated in spots, as from connective 
tissue induration subsequent to hsemor- 
rhagic infection, or catarrhal pneumonia ; 
lungs oedematous in lower portions, 
especiall}^ the left. 

Heart weighed 2 2 >^ oz., hypertrophy 
of all muscular structures of heart, and di- 
latation of all cavities, granulo-fatty 
degeneration of muscular tissue. Mitral 
ring stretched, papillar>^ muscles much 
thickened, and retracted, preventing 
closure or mitral valves. Mitral valves 
slightly thickened. Aortic and pulmonic 
valves were healthy. Tricuspid opening 
slightly stretched. A long firm white 
thrombus in right venticle stretched back 



into right auricle, and required some 
force to detach it from papillary muscles ; 
a small softer clot in left ventricle ; both 
ventricles and right auricle were filled 
with clotted blood. 

Iviver enlarged, firm and seat of fatty 
degeneration and moderate cardiac 
cirrhosis. Gall bladder distended with 
dark green bile, ducts patent. Stomach 
congested, slightly dilated. Pancreas en- 
larged, congested and very hard. 

Right kidney weighed oz., of 

normal consistency and appearance, cap- 
sule non-adherent ; ureter larger than 
normal. Left kidney weighed i}^ oz., 
capsule ver}^ much increased in thickness, 
impossible to separate it without tearing 
kidney tissue. Kidney itself very hard, 
contained in cortical portion several small 
cysts filled with an amber colored fluid, 
ureter ver}^ small. 

Dr. Skeer questioned the patient one 
morning as to his ever having had syphilis, 
and he said yes ; but in talking to him 
afterwards it was evident that he misun- 
derstood the doctor ; that he understood 
him to mean any kind of venereal disease. 
He had had gonorrhoea and admitted it, 
but he denied ever having syphilis. 

An examination of the specimen shows 
that the aortic valves are intact. It was 
opened between the junction of the two 
cusps of the valve, so that they are not 
destroyed. The mitral ring is considera- 
bly stretched and the valves are retracted, 
and it was rather difficult to state whether 
they have been the seat of more or less 
inflammation. Of course, they are thick- 
ened and retracted, but that might be due 
to the thickening and retraction of the 
ring and papillary muscles. The wall is 
much thickened, and the cavities are all 
dilated. The right kidney is of no par- 
ticular interest except that it is enlarged. 
In the left kidney there were several cysts. 
The}' were not opened, and they have 
dried up a good deal. 

These cysts are here found in their 
usual situation, that is in the cortical por- 
tion, especially near its surface. This 
kidney- is a marked example of the small 
red kidne}^ — chronic interstitial nephritis, 
the marked thickening of the capsule, 
and the direct connection of the capsular 
connective tissue with that of the cortical 
portion is ver^^ marked. The decrease in 
the cortical substance, especially that be- 
tween the pjTamids, is more marked than 
is usually found ; the pj^ramids them- 
selves have diminished considerably in 



94 



Society Reports. 



Vol. Ixvi 



size as the result of connective tissue in- 
crease in the medullary portion, a some- 
what infrequent occurrence. It is possi- 
ble that there was entire functional ina- 
bility^ of this organ for a long time, which 
might explain the absence of the usual 
evidences of disease found in the urine. 

A point of interest in this case w^as the 
diagnosis. It was evident the man had 
an hypertrophied and dilated heart, but 
it was not evident as to what that was 
due. There evidentlj^ had been hyper- 
trophy of the right ventricle which had 
taken considerable time in developing, 
and of course there must have been a 
cause for that. The aortic valves were 
intact ; there was no regurgitation or ste- 
nosis ; there was no apparent sclerosis of 
the arteries ; there was nothing that one 
could find yvhich would explain the en- 
largement of the heart, unless it might 
be contracted kidne}'. After administer- 
ing remedies to him and finding the secre- 
tion of urine was so free, and that it went 
on with the improvement of the circula- 
tion for months without any special trou- 
ble, there was no room to suspect that there 
was anything wrong with his kidneys. 
There was no evidence of any kidney 
disease by examining the urine, except 
occasionally traces of albumen, which 
will show in anj^ case of congestion of 
the kidneys from deficient circulation. 

Another point : It is evident that the 
enlargement of the heart would come 
under that head designated b}^ Fraentzel 
as idiopathic enlargement of the heart. 
It is due to some cause extraneous to the 
heart, obstruction to the circulation in the 
kidney, or some other agent ; excessive 
consumption of food and drink, for in- 
stance, might cause idiopathic enlarge- 
ment of the heart by increasing vascular 
tension. This case might be classed as 
one of idiopathic enlargement. How 
long this condition of the kidne}'- might 
have been developing it is hard to say ; 
but no doubt it was excited years prior to 
the man's death, or it may have developed 
in early life. How long a man would live 
with one kidney ; how long it would take 
to produce that amount of enlargement 
of the heart which we see in this case and 
its consequent failure are very interesting 
questions. It is possible the trouble with 
the kidney might have begun in earl}^ 
life. It is also possible that it might have 
been a matter of only five or six j-ears 
back. Certainly, it would take five or six 
3^ears for a heart to develop the condition 



of hj'pertrophy developed in this case, 
with the consequent degeneration and di- 
latation. In aortic stenosis, which gives us 
the form of hj^pertroph}^ more nearh^ allied 
to this than anything we can think of, 
we might have a heart running for a 
period of thirty or forty y^ears before it 
reached the condition of degeneration and 
dilatation which obtained in this man. 
The compensation effected by the right 
kidney is an interesting fact, as it must 
have done double duty for a long time, 
and while under rxiy obsen^ation I think the 
entire function devolved on this one organ. 
In no other waj^ can I explain the lack of 
evidence of kidney disease usuallj^ ob- 
tained b}' examination of the urine. I do 
not think the left kidnej^ excreted any- 
urine during the nine months in which 
the case was under m}^ obsen^ation. 

This case is also instructive in showing 
how much may be done in prolonging 
life in these cases under very- adverse con- 
ditions. 



SOCIETY REPORTS. 



PHILADEI.PHIA COUNTY MEDIC A Iv 
SOCIETY. 



Stated Meeting, December i8gi. 



The President, John B. Roberts, M. D., 
in the chair. 



Dr. a. B. Kirkpatrick read a paper 
on ' ' The Medical Treatment of Appendi- 
citis" (see page 84). 



DISCUSSION. 

Dr. Charles P. Noble : I arrived a 
little late, but I understand that refer- 
ence has been made to a case which I saw 
in consultation. It was undoubtedly a 
case of intussusception. The case illus- 
trates the fact that occasionally a patient 
will recover from this condition by 
sloughing of the bowel. It also illus- 
trates the difiiculties of diagnosis of the 
cause of peritonitis when the surgeon is 
called in late. The boy had been sick for 
nearly a week when I saw him. There 
was evident obstruction of the bowels, 
with faecal vomiting, and there was un- 
doubtedly well-marked peritonitis ; and 
the history indicated that the peritonitis 
had arisen in the right iliac region. The 
question was whether the case was one of 
appendicitis or one of intussusception. 
The physicians in charge were inclined 



January i6, 1892. 



Society Reports. 



95 



to regard it as a case of appendicitis, and 
and I agreed with them, as the symptoms 
of invagination were absent ; yet I must 
say that I felt that intussusception through 
the anus, but it was so high that my 
finger barely touched it, and I was not 
sure that it was not a fold in the bowel. 
. It is fortunate for that boy that our ad- 
vice was not followed ; for if he had gone 
to the hospital and been operated on in 
the condition that he was in, the chances 
would have been much in favor of a fatal 
result. At the same time, I think that 
it would be exceedingly dangerous to 
argue from such an exceptional case any 
general rule of practice. The recoveries 
in this class of cases, where the bowel is 
allowed to slough away, I think, does 
not exceed two or three per cent. 

Dr. T. S. K. Morton : The first case 
reported is of interest from the fact that 
it was a well-marked case of intussuscep- 
tion, and yet the classical symptoms of 
this condition were absent. There was 
no passage of blood with the stools, and 
there was absence of rectal irritation. 
The condition was about as marked as it 
possibly could be, and yet a diagnosis ap- 
parentl)^ was not possible. 

I think that the position of the surgeon 
in regard to appendicitis is often misun- 
derstood, especially by the mere medical 
practitioner. So far as I have seen, the 
surgeon is not anxious to operate, and 
the cases not operated on vastly exceed 
those in which operation is done. 

With reference to the constipation of 
appendicitis, I think that where the bowel 
cannot be moved by any procedure either 
from above or below, the case is exceed- 
ingly unfavorable for recovery, with or 
without operation ; whereas, if the bowels 
can be moved, the prognosis becomes 
much more favorable. If, after the bowels 
are freely moved, the symptoms subside, 
I look upon the case as one that will 
probably not require operation at that 
time. If, however, there is only tempo- 
rary amelioration of the symptoms, or 
none at all, the case is one for operation. 

Dr. William S. Stkwart : I am not 
satisfied that the cases reported should be 
regarded as true cases of appendicitis. 
There was evidently impaction of the 
ascending colon in all five cases, due, no 
doubt, to inflammatory action ; but it is 
evident that in these cases operation was 
not justifiable. First remove the impac- 
tion, and then if there is an aggravation 
of the symptoms, the imflammation be- 



coming more marked, it is then time to 
consider the propriety of surgical treat- 
ment. 

Dr. Kirkpatrick: I am sorry that no 
one has attempted to throw light upon 
the subsequent course of the first case re- 
ported, as to whether the typhoid condi- 
tion which followed was due to the inflam- 
matory trouble or was a true typhoid 
fever. 

I should not like to be considered, in 
this paper as not favoring operation in 
proper cases. The point which I wish to 
make is, that I fear in some cases the 
physician does not take the proper means 
to open the bowels before resorting to 
operation. I fully agree with Avhat has 
been said as to the unfavorable prognosis 
of operation in cases where the bowels 
cannot be moved at all. 

I think the criticism of (I believe) Dr. 
William S. Stewart hardly just or tenable. 
I understood him to say that he did not 
believe the cases reported were true cases 
of appendicitis — only obstruction of the 
bowel. I took particular care not to re- 
port in detail the cases in which I relied 
upon myself for diagnosis, but based my 
treatment upon the diagnoses of Drs. 
Keen, Noble, Wheeler, Dripps, and David 
Stewart. 

I think we must admit that they are 
careful, skilful men, and capable of mak- 
ing a correct diagnosis. 



THE STREAM OF IMMIGRATION. 

Reports to the State Board of Health, 
from the Sanitary Inspector in charge of 
the inspection of immigration to exclude 
dangerous diseases, at Port Huron, for 
the two weeks ending December 19, 1891, 
show opportunities for the introduction of 
such diseases, by immigrants from many 
different countries, passing through 
Michigan to States beyond. The num- 
bers and nationalities of the immigrants 
inspected were as follows :— 6 Arabs 
(from Jerusalem), 14 Austrians, 8 Bel- 
gians, 27 Bohemians, 49 Danes, 84 Eng- 
lish and Scotch, i Finlander, 34 French, 
97 French Canadians, 204 Germans, 20 
Hollanders, 10 Hungarians, 6 Irish, loi 
Italians, 209 Norwegians and Swedes, 
66 Poles, 12 Russians, 36 Russian Jews, 
2 Servians and 5 Swiss. 

The destinations of these immigrants 
were mainly ' ' Chicago and the North- 
west. ' ' A few of them went to Saginaw. 
All the French Canadians were from the 
province of Quebec. 



96 



Selected FormulcB. 



Vol. Ixvi 



SELECTED FORMULiE. 



CHOLBIvITHIASIS. 
Dr. Huchard (^Centralblatt fi'ir d. ges. 
Therapie, No. 8, 1891) recommends : 

T> Natrii benzdici, | 

XV Natrii salicyl, '•■aagm. t, 

Pulv. rad. rliei, ) 

Pnlv. nuc. vomic, gm v. 
Sufficient for twenty capsules. One capsule at eve y meal. 



ODORIvESS IODOFORM SALVE. 
The following (^Centralblatt fih^ d. ges. 
Therapie, No. 8, 1891) is suggested: 

T> Creoliu grammes j. 

-QiJ Iodoform *' ij. 

Vaseliii " xxv. 



BEJEAN'S GOUr CURE. 

According to the Pharmaceutische Cen- 
tralhalle, this remedy has the following 
composition : 

T>. Oil of wintergreeii parts v. 

Xjki , Extract of gentian " t. 

Iodide of pottesium " iv. 

Solium salicylate' " iv. 

Alcohol " XX. 

Water " Ixxx. 

M. 

LAXATIVE. 

"P Ext Colocynth Co 3 j. 

Ext. Hyoscyam. 

Aloes Pulv. Soc aa grains x. 

Ext. Nucis Vomicae " iij. 

Podophylli 

Ipecac aa " j. 

Make twelve pills, Sig. One ai bed-'ime. 

— Weekly Med. Rev. 



FISSURES OF THE TONGUE. 
The following {Lo Sperimentale , No. 
14, 1891) is recommended : 

T>, Acid carbolic grammes 2.5, 

-P^ Tinct. iodii ) 

Glycerine / 

INFANTILE INSOMNIA. 
M. Huchard gives the following : 

TJiethane gramme 0.20 

-Qu AquEe tilife destillaiaj. 

Aqufe aurantii flavse. 

Syrupi simplicis aa grammes 20 00. 

Sig. A dessertspoonful every two hours in a 
wiiieglassful of water. 

—Journal des Sciences Medicales de Lille, 
August 14, 1891, p. 166. 



FOR PELADA. 

Water of ammonia 1. 

Rum 3. 

Decoction of walnut leaves 40 to 60. 

Use as a lotion. 



TO PREVENT THE PITTING OF SMALL- 
POX VESICLES. 
Dr. Bertrand {Gaceta Sanitaria de Bar- 
celma, July, 1891) recommends : 

T>. Acid boric grammes 4. 

XV Amid, glycerolat " 5U. 

Apply immediately after the eruption appears. 



TOPICAL APPLICATION IN DIPH- 
THERIA. 

Dr. Ernest Timmermann writes in The 
Medical News that he has used with signal 
success the following formula as a topical 
application to the throat in the treatment 
of malignant diphtheria : 

T>. Acid sulphurosi f §ss. 

XV Liquor potassae gttxl. 

Aquae calcis ad f Siv. 

Mix, filter ; keep well corked in a cool place. To be 
applied topically to the th: oat by means ot a sponge, probably 
every huiir or two. 



CONSTIPATION IN INFANTS, 

Calcined magnesia, 
Powd. rhubarb, 

Oleosaccharum of anise, aa 5 parts. 
Administer a pinch of the above three times a daj' in 
the constip ition of children of 1 to 2 years oi l; if the infant is 
only s 'me »» fek-< old. make both the rhubarb and magnesia 3 
instead of 5 parts. [The oleosaccharum is made by intimately 
mixing one ur two irams of the essential oil of anise with one 
ounce of finely powdered sugar.] 



GONORRHCEA. 
Dr. Netzetzky (^JLa Independencia 
Medica, No. 42, 1891) uses the following 
injection in gonorrhoea : 

T>, Balsam copaibje grammes 4. 

-Pi Vitell ovi, No. 1. 

Aq. destillat grammes 180. 

f. emuls. et adde : 

Ext. belladon. ") ^ » - 

Zincisulfat. | aa dgms. o. 

Aq. laurocerat dgms. 4. 

Inject into the urethra four times a day. 

Of service in all forms of o:onorrhoea. 



FOR RHEUMATISM AND LUMBAGO. 

Hollister gives the following in doses 
of I teaspoonful three or four times a 
day : 

T>. Potassium iodide, grammes 15. 

XV Potassium hromide " 15. 

Tincture of colohicum seed... " 30. 

Pyrup of bitter orange-peel... " 50. 

Distilled water " 150. 

M. S g The dose should be augmented ui til the 
bowels ai e moved. 

— National Druggist, September 15, 
1891. 



ASTRINGENT GARGLES. 
The American Journal of Pharynacy 
gives the following formula for Goddard' s 
astringent gargle : 

Fol. rosse rub 2 dr. 

Aqu£e bullientis 5 oz. 

Acidi sulphurici dil. dr. 

Infuse, when cold strain, and add 

Mel. despumati 1 oz. 

A« idi tannici 2 scr. 

Aluminis 2 dr. 

sgLisr"""} 

M. 

Another gargle is as follows : 

Ked rose petals 2 dr. 

Pom egranate rind 4 dr. 

Boiling water 6 oz. 

Infuse, strain, and add 

Alum 2 dr. 

Clarified houey 1 oz. 

Mix, filter. 



January i6, 1892. 



Editorial. 



9t 



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LEADING ARTICLE. 

NEURASTHENIA, AND ITS RELATIONS 
TO MENTAL DISEASES. 

No subject within the entire range of 
medical science should demand more 
careful study at the present day than the 
protean-symptom-group we call neuras- 
thenia. Apart from the fact that in the 
eastern and northern parts of this country 
it is probably the most prevalent of all 
diseases, it should also ht remembered 
that it has been called the "American 
disease," by Beard, who, in 1868, de- 
scribed the conditions of nervous exhaus- 
tion under this collective name, and who 
also wrote that its development was 
directly due to ' ' modern civilization. ' ' 

We all have realized how frightfully 
common it is, and know that its expres- 
sion is more varied than even the mani- 
festations of ''malaria,'' and surely no 
other disease exists which is of more 
practical importance to the general prac- 
titioner, for it rests almost solely with 
him whether neurasthenia shall ' ' increase 
in the land." It is the general practi- 
tioner, the family doctor, who has the 
rarest opportunities for studying the 
beginning of these symptoms of lowered 
nervous tone, and who, therefore, must 
be most practically interested in their 
prophylactic and curative treatment, as 
well as in understanding, as far as our 
knowledge makes this possible, their real 
nature or pathology. 

Is it too much to say that the treatment 
of neurasthenia requires more experience, 
judgment and fine tac' than does that of 
any other known disease ? If this is so, 
and in our opinion it is at least very 
nearly so, certain accurate knowledge is 
essential to their proper understanding of 
any given case, for only upon correct 
ideas as to the real state of the nervous 
system exhibiting these varied symptoms 
can a useful therapeusis be based. It is, 
therefore, most desirable that everj^ phy- 
sician should, as far as possible, appre- 
ciate fully the meaning of every symptom 



98 



Editorial. 



Vol. Ixvi 



which may herald neurasthenia, so that 
in a very large proportion of cases its 
dangers can be averted. We fear that 
sometimes, we hope not often, deplorable 
results follow, because the physician in 
charge of the case disregarded, overlooked 
or neglected to give proper weight to 
early neurasthenic symptoms. 

So far, we have considered simple neu- 
rasthenia, or the symptoms of nervous 
exhaustion, but greater interest still 
attaches to this subject when we come to 
consider the relations which nerve ex- 
haustion bears to definite diseases of the 
mind. Are melancholia and mania, and 
other common varieties of insanity fre- 
quent sequences of neurasthenia ? What 
proportion of neurasthenics become in- 
sane? What proportion of the insane 
first suffered from neurasthenia ? Does 
insanity become more prevalent in pro- 
portion to the prevalence of neurasthenia ? 
These and many other questions natur- 
ally occur to us. 

Having endeavored to indicate a few of 
the reasons why neurasthenia should be 
of special interest to the general practi- 
tioner, it is our purpose to briefly sketch 
the subject as its literature reveals it 
to-day. Space will not permit of more 
than a brief synopsis of some of the latest 
and most important thoughts. 

Among the most valuable recent con- 
tributions to this subject, perhaps that of 
Dr. Edward Cowles (The Shattuck Lec- 
ture. Medical Communications of the 
Massachusetts Medical Society^ 1891) can 
be justly called the most thorough and 
complete, especially in more clearly than 
hitherto defining the relations which 
neurasthenia has with unmistakable 
mental diseases. The author of this 
valuable paper has had, from his wide 
experience as chief of the McIyCan Asy- 
lum at Somerville, Mass., the most ample 
opportunities for the careful study of this 
affection, and his large experience and 
scholarly attainments add weight to his 
words. He regards neurasthenia as a 
real pathological condition of the nerve 



centres due pjdmarily to overstrain, fa- 
tigue, etc.; secondarily to the exhaustion 
of other diseases ; and hereditarily to vari- 
ous exciting causes acting upon unstable 
cell nutrition. The underlying cause 
of the lowered nutritive activity of the 
cell protoplasm he mainly regards as an 
auto-intoxication from waste toxic pro- 
ducts, the result of over- functional work, 
or of disorders of the eliminating func- 
tions of the body, or of unstable metabolic 
action from bad heredity. In support of 
these views of the etiology and patholog}^ 
of ner^^e exhaustion, the author goes ex- 
haustively into the chemistry and physi- 
ology of the nervous mechanism, and 
also adduces all the recent proof which 
goes to show that auto-intoxication of 
the organism is more than probable in the 
conditions under consideration. This 
part of his work he sums up as follows : 
' ' The study of the general organic mech- 
anism, so far, shows that it may be con- 
ceived as made up of many minor mech- 
anisms which may be studied as repre- 
sented by their activities. Some general 
truths have been reached in regard to all 
of them as to their structure, their co-ordi- 
nations, and the results of their functional 
exercise. These conclusions are in sup- 
port of my first proposition, to the effect 
that when the mechanism is put into use, 
physiological activity and toxicity always 
occur together, and that the condition 
thus jointly produced has its first expres- 
sion in normal fatigue. Moreover, it 
appears that in pathological or nervous 
exhaustion, which constitutes neurasthe- 
nia, there results a condition of "exces- 
sive irritability and weakness ' ' of the 
nervous system. There is also, in acute 
neurasthenia, always an increased tox- 
icity, by its accumulation in fatigued 
areas, and often by general fatigue and 
auto-intoxication through disordered nu- 
tritional processes. ' ' 

Having thus concluded regarding the 
pathology of nerve exhaustion, he next 
demonstrates that there are mental symp- 
toms by which we may know the degree 



January 1 6, 1892. 



Editorial. 



of nervous fatigue and ' ' auto-intoxica- 
tion of the nerve and muscle elements," 
as a " guide for diagnosis, prophylaxis 
and treatment." Dr. Cowles says : " My 
observationsTin the treatment of insanity 
have given me the conviction that in the 
commonly occurring and typical forms of 
mental disorder, which are of a functional 
and curable character, nervous exhaus- 
tion always plays an important part, both 
in the attending conditions and the causa- 
tion." He strongly insists that the 
mental symptoms of neurasthenia being 
the earliest, are far more important, and 
better guides to treatment than the purely 
physical ones, and his treatment is based 
upon the recognition of the state of the 
nervous system from a careful study of 
the mentality of the patient. His treat- 
ment of the objective symptoms includes 
elimination, nutrition, rest, exercise, 
massage and the promotion of sleep. 

Dr. Dana, of New York, has recently 
given us a good definition of neurasthenia. 
(Neurasthenia. The Post Graduate, Janu- 
ary, 1891.) He says : "Neurasthenia is 
a morbid condition of the nervous system, 
whose underlying characteristics are ex- 
cessive irritability and weakness ; a con- 
dition in which the nutrition of the nerve 
cell is primarily at fault. ' ' 

It is now a well recognized fact that 
neurasthenia may confine itself to a 
limited area of the nervous system, hence 
we have the subdivisions of cerebras- 
thenia and spinal neurasthenia, with their 
legions of symptoms, chiefly subjective. 
Among the objective signs of the neuras- 
thenic condition. Dr. B. Sachs laj^s stress 
upon the following : tremor of the face, 
tongue and hands, and exaggeration of 
the knee-jerk. (Clinical Lectures. Inter- 
national Clinics, April, 1 89 1.) 

There can be no doubt from the mass 
of available evidence that neurasthenia 
and actual insanity possess, in general 
terms, the same etiology, and that the 
former may, and very commonly does, 
merge gradually into the latter. It is a nice 
question, sometimes, to decide between 



ordinar>^ acute melancholia and the men- 
tal depression which accompanies certain 
forms of neurasthenia, and probably the 
formation of delusions of persecution, or 
that the patient is being punished for 
imaginary crimes, constitutes the most 
really practical guide towards a decision 
in such cases. 

The treatment of these neurasthenic 
states is certainly most important in view 
of their natural tendency towards grave 
mental disease. It will often prove the 
prophylactic treatment of insanity. The 
success of any treatment depends mainly 
upon the recognition of the state of the 
nerves' mechanism, as shown, first, by the 
mental symptoms, and secondly, b}^ the 
subjective sensations and objective signs 
which the patient presents. Routine 
treatment of these cases (with strychnine, 
phosphorus and the various tonics, the 
rest cure, massage and electricity, foreign 
travel, etc.) is to be deprecated, for only 
will the needs of each patient be ascer- 
tained after a careful study of the type 
and degree of the nervous exhaustion 
based upon a thorough understanding of 
the real state of the nerve elements, as 
shown by the mental symptoms, together 
with the condition of bodily nutrition ; 
and, in all cases, it is our duty to endeavor 
to find out exactly what is interfering 
with nutrition. No subject within the 
scope of medicine is at times more per- 
plexing than the treatment of neuras- 
thenia, nor does any other disease oficr 
gTcater inducements for the proper solu- 
tion of the problem of treatment than 
nervous exhaustion. 

The practical lesson which the recent 
researches concerning the essential path- 
ology of nerve exhaustion should teach, 
seems to be that we should give increased 
attention to the mentality of neuras- 
thenics, since it is the earliest and most 
valuable guide, according to high authori- 
ties, to a correct appreciation of the 
nature and degree of the nerv^ous malady ; 
and, also, that the treatment of such 
states must be varied to suit individual 



lOO 



Correspondence. 



Vol. Ixvi 



cases, and the existing conditions of 
digestion, assimilation, cellular metabol- 
ism, elimination and excretion of toxic 
waste products. 

The intimate relation of nervous ex- 
haustion to insanity, on the one hand, and 
to neurasthenic symptoms on the other, 
plainly indicates that in all probability 
they are simply links in one pathological 
chain of events, and that many cases of 
insanity spring directly from neurasthe- 
nic soil, whether hereditary or acquired. 
Through the recent brilliant results 
obtained by the experimental chemist 
and physiologist, some of the shadows 
which obscure the patholog}^ of neuras- 
thenia have been cleared away, and 
enough is positively known to indicate 
that there is for nervous exhaustion 
always a definite pathological anatom}^, 
and that this consists of certain changes 
in the nerve cells, due to the effects of 
the toxic products resulting from their 
pathological activity. 

CORRESPONDENCE. 

PROMISCUOUS SPAYING OF WOMEN. 
DR. NOBI^B'S REPLY TO DR. TODD. 

Editor Medical and Surgical Re- 
porter : — It is much to be regretted that 
Dr. Todd in his communication in the 
last issue of the Reporter has fol- 
lowed the lines of his previous letter. 
He reiterates his statements, but fails to 
furnish any evidence in support of them. 
He is silent even with reference to the 
real nature of the four cases of removal 
of the uterine appendages which have 
come under his own notice. The only 
new point presented is that a woman, the 
mother of four children (whether with 
healthy or diseased ovaries the Doctor 
does not state, although presumabl}^ they 
are healthy), has consulted him with 
reference to having her ovaries removed 
in order to avoid further pregnancies, 
and that in spite of his advice to the 
contrary, she persists in her intention, 
and expects to get some surgeon to do 
her bidding, because she can pay for it. 
Also, that the woman knows several 
other women who have ' ' gone through 



the operation." Nothing is said as to 
the nature of the indication in these 
cases, whether tumor, abscess, or chronic 
salpingitis. It is not stated that any one 
removed this woman's healthy (?) ovaries, 
or agreed to remove them, but simply 
that the woman intended to have it done. 
Yet the Doctor says that this fact proves 
conclusively to him that there are certain 
parties who follow the profession of the 
promiscuous spaying of women ! It 
is scarcel}^ necessarj- to point out that the 
evidence required to convince him is not 
great. 

Dr. Todd says that his criticism applies 
to "a certain class of ambitious young 
surgeons." Here again he gives no 
reason for stating that ambitious young 
surgeons do other than justifiable opera- 
tions ; hence the statement does not re- 
quire special comment. 

As was stated in my last communica- 
tion, my object in writing it was not to 
criticise Dr. Todd, but to protest against 
the baseless assumption of not a few 
members of the profession that healthy 
ovaries are being removed by operating 
gynaecologists, and further, to protest 
against the present . fashion of making 
loose statements concerning this subject. 
This w^hole matter is a very serious one 
for the profession and for sick women ; 
and every candid and fair man must 
desire that it shall be approached, not 
from the standpoint of mere opinion, 
which may be only prejudice, but from 
the judicial or scientific point of view, 
in which truth is the only object, so that 
a conclusion can be reached upon evidence 
which is satisfactory to every mind. 

It seems curious that this subject now 
should agitate the minds of many mem- 
bers of the profession in general, when 
it has been settled practically by gynae- 
cologists themselves. Some years ago, 
following the lead, but not the moderate 
practice, of Battey,- surgeons removed 
many healthy or slightly diseased ovaries 
for various mental and nervous diseases, 
supposed to be connected with menstrua- 
tion. The results obtained, as might 
have been expected, were such as to 
cause the older gynaecologists to operate 
on such cases only after the failure of all 
simpler measures, and then only under 
strict limitations. This experience of 
the older men has been of immense 
advantage to j^-ounger men "in enabling 
them to escape this error in practice. 
Besides, our knowledge, or rather ap- 



January i6, 1892. Correspondence. 



lOI 



preciation, of the pathology of pelvic 
inflammation has undergone a complete 
revolution within the past ten years, 
which has been of the greatest value in 
giving gynaecologists to-daj^ a rational 
basis for their therapeutics. 

Had the letter of Dr. Todd, and 
similar communications, been written ten, 
or even five, years ago, they would have 
assisted in bringing about the principles 
of practice which the good sense of 
gynaecologists has caused them to adopt. 

The fact that a woman consulted Dr. 
Todd with the object of having the 
ovaries removed to escape future preg- 
nancies is worthy of careful consideration. 
It seems to me that an operation done 
for such a purpose would be malpractice. 
The only ground on which it could be 
justified would be in case of serious pelvic 
deformity, making delivery per vias 
naturales dangerous or impossible. But 
the modern Caesarean section, done at or 
just before the beginning of labor by an 
expert surgeon, is so safe that even here 
the indication is very questionable. 
Very respectfully yours, 

Charles P. Noble, M. D. 



NON-MENSTRUATING PLURIPARA. 

Editor of the Medical and , Surgi- 
cal Reporter : — On page 834 of Re- 
porter, of volume Ixv, Dr. Marion 
Dunagan quotes a case of a colored 
woman who had never menstruated, who 
was the mother of ten children. Will 
you allow me to report the following : 

In 1878, I attended a Mrs. D in her 

sixth confinement. She stated to me, and 
her husband confirmed the statement, 
that she had never menstruated and 
never wore a guard. She sent for me a 
month before delivery, believing herself 
at full term, stating that she "did not 
know for a certainty when she was at full 
term," owing to the fact that the usual 
data were not present to date from. 
Afterward she gave me in a vial two ova, 
unruptured, which she had found on her 
night dress. 

I believe Dr. Dunagan is right as to 
menstruation and ovulation not occurring 
at the same time, and that neither are 
dependent on the other. I have a record 
of eleven cases where connection was not 
had with the woman until fourteen or 
fifteen days after menstruation and for a 
month prior to it, and still conception 
took place. In two other cases women 



have shown me the perfect ova which 
have been thrown off sixteen or twenty 
days after menstruation — they not know- 
ing what " the little pellets " were. 

I have no doubt but that numbers of 
physicians have met such cases but 
thought them of not sufficient importance 
to report. 

Incidentally, I may state that I know 
also of a case where a lady of eight}^- 
three who menstruated regularly ever}^ 
two months, the same as when she was a 
young woman. She had never menstru- 
ated every month as is usual. 

Ben. H. Brodnax, M. D. 

Brodnax, La. 

DR. E. W. CAMPBELL'S ARTICLE ON 
"ELEMENTS OF THOROUGH 
DIAGNOSIS." 

Editor of the Medical and Surgi- 
cal Reporter :— Dr. E. W. Campbell 
in his article in the Dec. 26th issue of the 
Reporter, entitled, "Elements of 
Thorough Diagnosis," afi'ords a remark- 
able example of the fact that certain 
impressions transmitted by the optic 
nerve, under certain conditions, can so 
influence the brain as to make it repro- 
duce the same impressions on some other 
occasion with the belief that they are 
original. The case above cited is remark- 
able in that the ideas of the article and 
the language by which they are expressed 
are identical with part of the introduction 
to Da Costa's " Medical Diagnosis." 

I feel obliged to the author of the 
article for placing in my hands so con- 
venient a copy of the instructions of the 
great Da Costa. 

Respectfully, 

J. F. Stewart, M. D., 

Griffen, Ga. 

constipation. 

In a lecture on Constipation, the emi- 
nent authority on therapeutics. Prof. 
Dujardin Beaumetz, described Villacabras 
as the most highly concentrated purga- 
tive water known. Its usefulness seems 
to be by no means limited to the field 
which is occupied by other waters. Its 
action is not succeeded by the annoying 
constipation that usually follows the ad- 
ministration of other purgative waters. 
An ordinary wine glass of Villacabras, 
taken before breakfast, produces a sooth- 
ing effect upon the bowels and results in a 
natural movement within two or three 
hours. 



I02 



Periscope, 



Vol. Ixvi 



BOOK REVIEWS. 



THE COjMPARATIVE ANATOMY OF THE 
DOMESTICATED ANIMALS. By A. Cha- 
teau, M. D., LL D. Second English Edition. 
Translated and Edited bv George Fleming. 
C. B.. LE. D., F. R. C. V. S. Svo, pp. 1084, 
5S5 illus. New York : D. Appleton & Co. 
1891. 

This edition is a translation of the 
fourth French edition, issued last 3'ear. 
In the present volume, numerous altera- 
tions, additions and illustrations have 
been made in order to render it fully up 
to the requirements of a text-book and 
standard work of reference. The chief 
additions are on the anatoni}^ of the ass, 
mule, rabbit and camel, and one hundred 
and thirt}" new illustrations. The pages 
have been enlarged, and the letter-press 
substantiall}^ improved. There is also a 
copious index, which is not found in the 
French edition. 

Chaveau's work has long since attained 
a position second to none in the field it is 
intended to cover. In this new edition, 
the student of veterinan,' and comparative 
anatomy will find a work accurately 
written, full}^ illustrated and generalh' 
admirabh^ adapted to his wants. 



EVIDENCES OF THE COMMUNICABIEITY 
OF CONSUMPTION. Bv G. A. Heron, 
M. D. (Glas.), Fellow of the Royal College of 
Physicians of London ; Phj'sician to the'City 
of London Hospital for Diseases of the Chest. 
Svo, pp. 163. Loudon and New York : Long- 
mans, Green & Co. 1890. 

During the winter of 1889, Dr. Heron 
delivered two lectures at the London Hos- 
pital for Diseases of the Chest, on ' ' The 
Question of the Communicabilit}' of Con- 
sumption." These lectures met with 
such approval, and were of such value 
for reference, that he has been induced to 
put them in book form. 

The death-rate from tuberculosis is so 
appalling that an3'one offering facts which 
will serve to diminish it, must be looked 
upon as a public benefactor. Certainly 
the lectures before us entitle the author 
to such a recognition. 

In the book, the wording of the origi- 
nal lectures has been somewhat modified, 
additions have been made, but the collo- 
quial style of the lectures presented. We 
find chapters on the researches of Koch 
concerning tuberculosis, the evidences 
of the connection of specific bacteria with 
the disease, the haunts of the bacilli, the 
evidences showing the communicability 



of consumption, milk and meat as sources 
of infection, proph^'laxis, etc. There is 
also a valuable appendix b}' Dr. Frosch, 
of Berlin, prepared under the direction 
of Professor Robert Koch, giving refer- 
ences to recent contributions on the in- 
fectiousness and contagiousness of this 
disease. 

Dr. Heron is a firm believer in the 
bacteriological origin and contagiousness 
of consumption, and his facts have been 
presented so clearl}^ and convincingh^ 
that one cannot read his work without 
feeling that he has built upon an inde- 
structible basis. The book is of such a 
character as will interest ever}' one hav- 
ing the welfare of the community at 
heart, and who desires to prevent the 
spread and continuance of this terrible 
scourge of mankind. 



PERISCOPE. 



THERAPEUTICS. 



THE HYPNOTIC ACTION OF THE ANTI- 
PYRETICS. 

In the Deutsche Medizinal Zeitung for 
June 5, 1 89 1, Professor Bernheim calls 
attention to the great similarit}' in action 
of the so-called antip^-retics, — quinine, 
salicjdic acid, antipj^rin, antifebrin, phen- 
acetin, etc., — not onh^ in their antither- 
mic, but also in their hj'pnotic action. 
When the favorable action of salic3dic 
acid in rheumatism was first observed, it 
was designated as a specific for this affec- 
tion, but experience has taught that the 
other antithermic remedies produce a 
favorable effect likewise in the same 
manner, — that is, they diminish articular 
pain without influencing the course of 
morbid processes itself. According to 
Bernheim, the connection between anti- 
thermic and analgesic action is the fol- 
lowing : Fever originates through the 
absorption into the blood of pyrogenic 
substances, which act as stimulants to 
the heat-centres, and reduction of tem- 
perature can be produced b}' the elimina- 
tion of these p\'rogenic substances or by 
direct action on the heat-centre. If the 
antithermics were capable of actually de- 
stro^'ing the ferments in the blood thej^ 
would then act as abortive agents. This 
is, however, not the case, according to 
Bernheim, who will not even admit a 
specific action for quinine in the case of 
malaria, since he maintains that the 



Periscope. 103 



January 16, 1892. 

action of this substance on the disease 
is merely due to its antithermic proper- 
ties, which are possessed in almost equal 
degree by the other antithermics. He 
concludes that the different antipyretics, 
quinine and salicylic acid included, only 
produce their action either through anti- 
thermic influence on the cerebral centre, 
and that a distinct antipyretic action 
within the organism has never been de- 
monstrated. He likewise maintains that 
the analgesic action is in close connection 
with the antithermic action, and like- 
wise is produced by influence of nerve- 
centres, which are probably included in 
the gray substance of the cortex. In 
fact, Bernheim states that by the aesthe- 
siometer he has succeeded in producing 
marked reduction in the sensibilit}^ of 
the skin after the exhibition of quinine. 
According to this, therefore, the antipyre- 
tics are only indicated in fevers in the 
height of temperature, or when they are 
to be employed for the reduction of 
abnormally increased sensibility. 



CORNUTIN AS A HEMOSTATIC IN HEM- 
ORRHAGES FROM THE BI.ADDER 
AND FEMAIvE GENlTAIvS. 



Dr. Wilh. A. Meissels ( Wiener med. 
Presse, No. 42, 1891) recommends cor- 
nutin muriate or citrate as an efficacious 
haemostatic in vesical and uterine haemor- 
rhages. It may be administered subcu- 
taneously or by the mouth. It is equally 
e£&cacious in males as well as in females. 
The dose employed was one to one and 
a half centigrammes (one-eighth to one- 
fourth of a grain) a day. It is easily 
taken and supported by the stomach. 



CHLORIDE OF AMMONIUM IN INFLU- 
ENZA. 



According to the Paris correspondent 
of the Lancet, at a recent meeting of the 
Academy of Medicine, M. Marrotte ad- 
vocated the use of chloride of ammonium 
in the treatment of epidemic influenza in 
preference to sulphate of quinine, as 
urged by M. Gellie, of Bordeaux, in his 
recent paper read before the academy. 
M. Marrotte speaks very highly of the 
results obtained by chloride of ammon- 
ium, the advantages of which over qui- 
nine he claims to be that it is much 
cheaper, more rapid in its action, and 
brings about a more complete and defi- 
nite cure. It is more especially in those 



forms of the disease which are compli- 
cated b}^ pulmonary congestion or inflam- 
mation that chloride of ammonium, will 
be found serviceable. From 50 to 80 
grains may be given in twenty-four 
hours in the form of 8-grain powders, 
which ma}" be conveniently concealed in 
a wafer. As the treatment of influenza is, 
unfortunatel}^, like many other thera- 
peutic problems, a very open question, 
perhaps some of 3'Our readers on your 
own side of the channel, whose oppor- 
tunities just now are only too unlimited, 
might put the drug to the test and record 
their experience. 



HYDROTHERAPY IN THE TREATMENT 
OF DIPHTHERIA. 

The whole body of the child from the 
neck down is enveloped in a Priessnitz 
pack. This is removed at the end of 
three hours and the whole body rubbed 
off with cool water. After this, the body 
is again enveloped in the Priessnitz pack 
from the neck to the hips. These packs 
are renewed about every fifteen minutes 
during the following hour or two. 

This whole procedure repeated twice, 
so that the child lies in a constant sweat 
from six o'clock in the morning to twelve 
o'clock at night. To promote diaphore- 
sis, elder-tea and cognac in sugar water 
are freely administered. 

From midnight until six o'clock in the 
morning, the child is allowed to rest, 
only a small Priessnitz pack enveloping 
the neck. Internally, chlorate of potash 
(2 per cent.) is administered. 

This treatment usually causes the 
membrane to disappear within from two 
to four days. The fever and the bad 
smell as a rule vanished on the second 
day. The more copious the perspiration, 
the more rapidly does the membrane 
loosen. 

Out of 117 cases of diphtheria treated 
as above described, 14 died. Trache- 
otomy was required in 9. The time spent 
in the hospital varied from six to eight 
days for each gase. 

As a theoretical argument in favor of 
the sweat treatment, it may be stated that 
it augments pressure of the secretion in 
the mucous glands, thereby loosening the 
false membrane, which is especially held 
in place by the fibrin net sunk into these 
glands. Moreover, the stimulation of the 
lymphatic circulation promotes the elimi- 
nation of the poisonous elements from 
the hoAy—Blatf. Klin. Hydroth. 



fe 



I04 



Periscope. 



Vol. Ixvi 



TREATMENT OF ANGINA PECTORIS BY 
COCAINE. 

In a paper in the Revue de Medicine, 
the use of cocaine is strongly recom- 
mended in angina pectoris, in doses of 
one-half to one- third of a grain three or 
four times dail}^ He quotes four cases 
of this disease which were benefited 
g-reatly by this treatment. If the attacks 
do not cease immediately after taking 
the remedy, they completely yield to it, 
however, in about three days. Under its 
use the pulse becomes slower but fuller, 
and the quantity of the urine is aug- 
mented. The author refers to some ob- 
servations previously made by him, which 
appeared to show that the inhalation of 
oxygen in this disease did much good ; 
he therefore suggests that it should be 
tried ^in conjunction with the internal ad- 
ministration of cocaine. — Med. Chronicle. 



A NEW TREATMENT OF GRANULAR 
CONJUNCTIVITIS. 

The usual treatment of granular con- 
junctivitis consists in turning back the 
eyelids with the fingers, and then cauter- 
izing the portion of the conjunctiva thus 
exposed with the sulphate of copper. 
This daily cauterization is extremely 
painful, and does not produce cure until 
after many weeks of severe suffering, and 
sometimes did not prevent absolute blind- 
ness. 

At the meeting of the Academic de 
Medecine, held on August 4, 1891, Dr. 
. Abadie described a method in the first 
place of completely everting the upper 
eyelid so as to expose the superior con- 
junctival cul-de-sac (^La France Medicate, 
August 7, 1 891). In the ordinar}^ method 
of procedure it is this part of the superior 
cul-de-sac which is never exposed, and 
which is ordinarily a veritable focus of 
infection. To accomplish this complete 
inversion of the eyelids special instru- 
ments are necessary, and the patient must 
be chloroformed on account of the severe 
pain produced by this mauoeuvre. The 
eyelid .is seized with forceps, and then 
rolled twice upon itself, or, in other words, 
rolled twice completely around the for- 
ceps, so as to completely expose the 
superior conjunctival cul-de-sac, which is 
then scarified freely with a bistoury, and 
a fairly hard tooth-brush is then dipped 
in a solution of corrosive sublimate, i to 
500, and the raw surface vigorously 
brushed with this solution. This pro- 



cedure is only required once, and then on 
subsequent da3^s the eyelids are simph' 
everted in the ordinary manner and the 
conjunctiva bathed with a solution of 
sublimate. The author states that this 
method of treatment maj^ be applied to 
all cases, no matter what may be the 
existing degree of complication, and that 
its efiicienc3" is the more marked the 
more serious is the case. 

Dr. Guaita recommended first the use 
of sublimate in strong doses ; Sattler in- 
sisted upon the efiiciency of scarifications 
combined with scraping of the granular 
tissues ; while Manolescu suggested the 
use of the brush ; but the value of the 
procedure depends upon the employment 
together of all these procedures, which 
individually are inefficacious, and upon 
the complete exposure of the superior 
cul-de-sac. 



LOCAL AND GENERAL ANAESTHESIA. 

Grandclement {Lyon Medical, Nov. 12, 
1 891) states that local anaesthesia usuall}^ 
sufiices for the performance of minor opera- 
tions, such as the relief of ingrowing 
nails, opening of abscesses, enucleation 
of small, superficial tumors, or to over- 
come the circumscribed pain of infiam- 
mation or of neuralgia. Several methods 
have been proposed for the purpose, but 
all are not equally valuable or secure. 

1 . AncBsthesia by congelation with tlie aid 
of a refrigerant viixtitre of salt and ice was 
the only method used twent^'-five or thirt}' 
3'ears ago ; to-day it is almost abandoned. 
It is painful and time-consuming, and is 
best applicable to the extremities, the 
toes or fingers, which can be plunged 
into the mixture. Besides, ice cannot 
alwaj^s and everywhere be obtained. 

2. Spraying with ether originated with 
Richardson twenty-five years ago. It is 
superior to freezing with ice ; it requires 
a special apparatus and protracted appli- 
cation, and is sometimes quite painful. 

3. Sp7'aying with ethyl chloride has re- 
cently been recommended. Ten grammes 
of ethyl chloride contained in a small 
glass bulb, terminating in a capillar}^ 
tube that has been sealed in the flame of 
a lamp, are vaporized by the heat of the 
hand (eth5-l chloride vaporizes at + 10° 
C. (50° F.). A fine spra}^ escapes when 
the tube is broken. In a short time the 
area sprayed presents a white appearance 
and a degree of anaesthesia sufficient to 
open deep abscesses and to perform other 
minor operations. 



January i6, 1892. 



Periscope. 



4. Hypodermatic mjediojis of cocaine in- 
duce phenomena of profound intoxication 
in certain individuals, even when small 
doses are employed. Unpleasant symp- 
toms sometimes follow the instillation of 
cocaine into the conjunctival sac. In the 
violent periorbital neuralgias that are pro- 
voked by certain affections of the eye, 
Grandclement has obtained good results 
from injections of cocaine and antipyrine 
in association. He believes that the 
oedema and vascular stasis resulting from 
the injection prevent too rapid absorption 
of the cocaine. The same end is attained 
by applying an Esmarch bandage to the 
part before the injection of cocaine is 
made. Grandclement has observed that 
the anaesthesia produced by the mixture 
of cocaine and antipyrine persists for 
several days. 



THE NATURE AND TREATMENT OF 
STAMMERING. 

Kmil Behnke {Jour. Laryngology and 
Rhi7iology, July, 1891) has recently de- 
clared that the terms stammer and stutter 
should indicate the same condition, re- 
jecting a former distinction that stammer 
should refer to that form of obstruction 
in which there is inabilit}^ to pronounce 
vowels, and stutter to that form of im- 
pediment in which the consonants are at 
fault. The causes of these disturbances 
are attributable to the nervous centres 
controlling the mechanism of respiration, 
phonation and articulation. 

Children afflicted with stammering do 
not, as a rule, outgow the habit ; ridicule 
•or severity will increase the difficulty. 

Conditions needing surgical or medical 
interference, such as spinal curvature, 
post-nasal adenoids, decayed teeth, in- 
testinal worms and phimosis, ma}^ pre- 
vent cure of stammering until their 
removal. 

Cases of stammerers are divided into 
two classes — those in which fault lies in 
management of respiratory apparatus, 
and those in which it does not. In the 
former the prognosis is more hopeful. To 
test patient, he is placed flat on his back 
upon a couch, and is drilled in methodized 
and graduated series of sounds and in- 
spiration, produced by diaphragm and 
muscles of abdominal walls, the hand of 
the trainer upon the epigastrium accentu- 
ating these movements. 

If, after such practice, the patient shows 
improvement, a favorable result may be 
expected from treatment. In those cases 



in which obstruction does not depend 
upon imperfect respiration, Behnke at- 
tributes much of trouble to "an involun- 
tary exaggeration of all the stops and 
checks taking place in vocal apparatus 
from glottis to lips, and he must therefore 
be trained to make these closures as 
shortly and lightly as possible." Thus 
a short aspirate may be inserted after a 
consonant ; as G-h-eorge, instead of 
George, or, as patient would say, 
G-g-g-eorge ; and p-h-a, instead of pa. 

Stammerers sing and whisper without 
difficulty, because in singing there is 
almost continued tone, and in whispering 
there is absence of tone. It is advised 
to dwell on vowels at expense of con- 
sonants — and if vowel difficult to sound, 
it should be preceded by a short inspira- 
tion. Another beneficial exercise is to 
speak slowly, with teeth overlapping and 
pressed tightly together. 

Result of treatment influenced by se- 
verity of case, intelligence of patient, 
also existing morbid conditions, especially 
those due to chorea or other nervous dis- 
turbances. 

SOME OBSERVATIONS ON THE USE OF 
PIPERAZINE. 

Dr. Heubach, assistant in the Clinic of 
Prof. Zuelzer, in the Johanneum, Berlin, 
says, Jnternat. Centralblatt fi'ir die Physi- 
ologic u. Pathologic der Ham. u. Sexii- 
alorgane) for several months back have 
been making trials with piperazine in 
their clinic and polyclinic. This base, 
which is readily soluble in water 
and strongly alkaline in solution, has 
the chemical formula C4H10N2, and in 
constitution is a piperidin in which 
the CHo group has been replaced by 
the NH. It is now manufactured on 
a large scale (by the Chemische Fa- 
brika. A., vorm. Shering, of Berlin) 
and has been therapeutically employed 
in various quarters, notably by Ebstein 
and Sprague, Vogt, Bardet and others. 

By these observers the remedy was pre- 
ferably tried in cases of gout, and also on 
patients in whom it was necessary to dis- 
solve uric acid concretions in the kidneys 
(gravel and urinary calculus). The ap- 
plication was suggested b}^ the fact that 
piperazine experimentally dissolved large 
quantities of uric acid in test tubes at 20° 
C. (68° F.) ; that the urate combination 
of piperazine, furthermore, was at least 
seven times more readily soluble than the 
hitherto therapeutically preeminent car- 



io6 



Periscope. 



Vol. Ixvi 



bonate of lithium, and finally that the 
base, even in the presence of excess of 
uric acid, produced no acid but an easily 
soluble neutral salt. 

Kbstein and Sprague furnish a table of 
results, produced on a patient with uric 
acid diathesis by seven days treatment, 
with increasing dosage of i to 3 gm. 
piperazine. This table gives the impres- 
sion that the volume of urine was in- 
creased thereby ; in one case the exhibi- 
tion of 2 gm. of piperazine increased the 
volume from 1250 to 2160, and in another 
instance even to 2270 ccm. in 24 hours, 
while the sp. gr. was similarly reduced. 
In addition the acid reaction of the urine 
was considerably reduced, and in one case 
became alkaline. The uric acid, w^hich, 
according to Vogt, is reduced in propor- 
tion with urea, does not show this action. 

In collaboration with Dr. Kuh, he un- 
dertook a series of experiments, both of 
them taking at the same time, without 
change of regular diet, 2.5 gm. pipera- 
zine one day, i gm. the second, and 2 
gm. the third da)^ dissolved in a glass of 
seltzer- water. Within two hours after 
taking the piperazine it could be found in 
the urine. 

The urine was tested in separate por- 
tions, three taken during the day and 
during the night. 

After administration of the largest dose, 
2.5 gm., an inconsiderable increase of 
urine volume was noted in both persons 
— in one to 2260, and the other 1970, ccm. 
in 24 hours. The reaction alw^ays re- 
mained acid, and the specific gravity was 
not heightened. One gramme doses low- 
ered the volume to a normal amount, 1630 
and 1500 ccm., alv/ays acid. 

The quantity of urine was not in- 
creased ; the sp. gr. also continued within 
normal limits. The reaction of the urine, 
estimated alkalimetrically, was always 
acid, and approximately amounted to the 
normal, 2.29 with one, and with the other 
1.75 g. HCl.^ 

To determine the effect on metabolism 
they selected N. (nitrogen) and P2O5 (phos- 
phoric acid). The nitrogen (resp. urea) 
showed no increase — resp. 11 and 10.8 in 
24 hours ; nor did the phosphoric acid, 
which amounted to 2.4 and 2.3 g. Con- 
sequently the relative amount of the lat- 
ter continued normal, viz., 22.4 and 21.6. 

Corresponding with this showing, the 
use of piperazine induced no disturb- 
ance in their general condition ; but it 
must be noted that after taking the largest 



dose (2.5 gm.) both persons experienced 
very severe headache on the following 
morning, and in one vomiting occurred. 
The smaller doses of i gramme were 
taken regularly for several days consecu- 
tively without causing an}^ derangement. 

As regards the uric acid, a ver}^ small 
increase (0.78 and 0.49 g. in 24 hours) 
was shown in all cases. 

A trial was made to see if urine con- 
taining piperazine would dissolve uric 
acid ; the result, even at high temperature 
and with extended action, was decidedly 
negative. 

The therapeutic trials which they then 
undertook yielded distinct success in two 
cases of lumbago ; both were treated by 
subcutaneous injections of a 2 per cent, 
solution. Patients received 0.5 gm. doses 
four times daily, a total of 2.0 gm. in 24 
hours. Improvement in conditions was 
noted on the third and fifth days, and on 
the ninth and tenth days both patients 
were free from pain. The injections, 
they state, were in themselves quite pain- 
ful, but they did not cause abscesses, nor 
were ih&y followed by unpleasant after- 
effects. For subsequent use of the remedy 
they prefer to use voluminously^ diluted 
solutions. 

Piperazine deserves particular attention 
in uric acid concretions in the kidnej^s. 
They had opportunity to study two such 
cases in detail, and they proved remark- 
able, because of the exceedingly favorable 
results. 

These two cases, in connection with the 
cases reported by Bardet, speak distinctly 
in favor of a specific effect of piperazine, 
and show the advantage and desirability 
of further therapeutic observation in this 
direction. 



ACTION AND USES OF FIIvICIC ACID. 

The isolation of the active principle of 
male fern has acquired toxicological 
interest of late, on account of the occur- 
rence of several fatal cases of poisoning 
attending the therapeutic employment of 
the extract. The toxic properties of 
filicic acid are still disputed. It is un- 
certain whether filicic acid possesses toxic 
properties. Much, however, depends 
upon whether we employ the pure crys- 
talline product or the crude precipitated 
acid. Herr Poulsson shows that these 
two modifications differ in their physio- 
logical and chemical relations ; that 
there is but little doubt that the inactive 
crystalline body is an anhydride or lac- 



January i6, 1892. Periscope, 



107 



tone of the amorphous filicic acid, and is 
better termed fiUcin. Filicic acid is well 
adapted for therapeutic purposes, as it is 
easily dissolved, held in solution in the 
intestines, and is only very slowly ab- 
sorbed ; thereby explaining how it effects 
the expulsion of parasites. ThCvSe re- 
sults explain why a freshly-made extract 
of male fern is more active than in older 
preparations, — The Pharm. Joiirn. and 
Trans., p. 85, August i, 1891. 



HYPNOTISM. 

In a paper read before the Colorado 
State Medical Society, Eskridge (^New 
York Medical Journal, August i, 1891) 
stated that hypnotism is real and subject- 
ive and not dependent upon any mysteri- 
ous influence of the hypnotist over the 
subject. The therapeutic value of hyp- 
notism is governed by the mental im- 
pressions made during hypnosis, a state 
of increased impressionability. Much 
that is accomplished by hypnotism may 
be accomplished by repeated impressions 
without hypnosis. Hypnotism carries 
with it certain dangers to the hypnotist, 
to the subject and to the community, to 
be obviated by proper precautions. It 
remains to be determined whether or not 
the therapeutic value of hypnotism is 
greater than the unavoidable dangers of 
its application. The practice of hypnot- 
ism should be under state control and 
restricted to physicians and other scientific 
investigators. 



MEDICINE. 



ACTION OF UREA ON THE VASCULAR 
WALLS. 

Dr. Munk, several years ago, on per- 
fusing blood to which urea w^as added 
through a surviving kidney, found that 
the addition of urea accelerated the 
blood stream, and increased the secretion 
from the kidneys. This result was also 
produced by sodic chloride, the sulphates 
and phosphates of the alkalies, creatin, 
sugar, creatinin and other substances. 
The vaso-dilator action of the urea on 
the kidneys was not due to the action of 
the urea on the central nervous system, 
for it occurred in the excised and still 
living kidney. Cavazzani and Rebustello 
have made somewhat similar experiments 
by perfusing blood mixed with urea 
through several organs, but in all cases 
the organs or parts were left in situ. 



The fluid perfused was i part of bullock's 
blood mixed vv^ith 2 parts of normal saline 
solution (0.75 per cent, common salt). 
The animals employed were dogs, cats 
and rabbits. The quantity of urea added 
to the blood varied from 0.5 per cent, to 
eight per cent, as a maximum. Urea 
possesses a marked vaso-dilator action 
not only on the blood vessels of the 
kidney, but also on the vessels of the 
brain, liver and musculo-cutaneous ves- 
sels in the last case, as shown by its 
action on the blood vessels of the hind 
limbs. Speaking generally, the vaso- 
dilator action of urea is directly propor- 
tional to the quantity per cent, of urea 
present in the blood. The minimum 
percentage of urea required to cause vaso- 
dilatation is for the kidneys 0.5 per cent, 
and for the other organs mentioned one 
per cent. In opposition to Munk, the 
authors have never observed a secretion 
of true urine during their experiments. — 
British Medical Journal. 



DISORDERS CAUSED BY TRICO- 
CEPHALUS DISPAR. 

Dr. Moosbrugger {Jahr.J. Kindhlkde, 
xxxiii, p. 137, from Witrttemberg med. 
Correspondzbl?) questions the usually ac- 
cepted statement that tricocephalus dis- 
par does not cause symptoms. He has 
found four recorded cases in which serious 
nervous symptoms were attributed to it, 
and adds a fifth case, a boy, aged 
years, who for six months had had diar- 
rhoea of gelatinous slimy stools (some- 
times blood-stained), had suffered from 
spasmodic cramps of the arms and legs, 
and had deteriorated very much in gen- 
eral health. The presence of progressive 
anaemia suggested the possibility that 
the child might be the host of anchylos- 
toma duodenale ; an examination of the 
faeces, however, showed the presence of 
the eggs of tricocephalus dispar in such 
enormous numbers that Professor Leich- 
tenstern calculated that the child was 
passing about 3,000,000 eggs with its 
stools every twenty-four hours ; he 
further calculated that to yield this num- 
ber of eggs there must have been from 
1,000 to 2,000 female worms in the child's 
intestines. Treatment by santonin, ca- 
lomel, male fern, dry clysters of garlic, 
tobacco, yellow iodide of mercury, and 
decoction of pomegranate, met with little 
success, only two worms (one male and 
one female) being expelled. However, 
during a severe attack of feverish bron- 



io8 



Periscope, 



Vol. Ixvi 



chitis the}^ were passed spontaneous!}^ in 
large numbers. Their injurious effect on 
the host is to be attributed in part to ab- 
straction of blood and serum, and partly 
to reflex irritation. Infection is believed 
to take place usually hy the ingestion of 
imperfectly cleansed vegetables, but in 
this case the child was in the habit of 
sucking and swallowing garden soil. — 
Brit. Med. Jour. 



KERAUNO-NBUROSES. 

Frankl-Hochwart {Zeitschr. f. klin. 
Medicin, Bd. xix, H. 5 u. 6, 1891) 
describes as kerauno-neurosis a condition 
that develops in persons who have been 
struck hy lightning. The S3^mptoms are 
those characteristic of the traumatic 
neuroses, and include palsies, tremor, 
derangement of common and of special 
sensation, limitation of the visual fields, 
ataxia and exaggerated reflexes. 



SPASTIC INFANTILE SPINAL 
PARALYSIS. 

Dr. Pierre Marie {Gazzetta degli 
Ospitali, No. 57, 1891) thinks the prog- 
nosis not absolutely unfavorable ; an 
amelioration ma}^ take place in three to 
ten 3^ears. A certain degree of rigidity 
will always persist. Regular and non- 
violent massage, using large, passive 
movements, warm baths and galvaniza- 
tions of the medulla, are the most effica- 
cious means known. 



THE SPECIFIC GRAVITY OF THE BLOOD 
IN HEALTH AND IN DISEASE. 

As a result of a series of fifty-four ob- 
servations in conditions of great diversit}^, 
Siegl {Wiener klin. Woche7ischr., iv, 33, 
1 891) has arrived at the following con- 
clusions : 

1. The specific gravity of the blood is 
dependent upon the proportion of haemo- 
globin and is independent of the number 
of blood-cells. 

2. Diseases, acute as well as chronic, 
onl}^ affect the specific gravity of the 
blood when they have " led to gradual 
prostration. Rapid loss of strength, on 
the contrary, appears to exert but little 
influence. In the course of diseases in 
which the blood is contaminated b}^ the 
products of pathological tissue metamor- 
phosis, or in which the blood is deficient 
in its normal chemical constituents, there 
is, in addition to an absolute change in 
the specific gravit}^, a disproportion 



between the specific gravity and the per- 
centage of haemoglobin. In hepatogen- 
ous jaundice, in diseases of the lungs or 
of the heart attended with cyanosis, in 
diseases attended with loss of bodily 
fluids, the specific gravity is (relatively 
to the percentage of haemoglobin) raised. 
When the blood is deprived of albumen 
as a result of albuminuria, and probabl}^ of 
long-continued suppurative processes, the 
specific gravit}^ is lowered. In renal dis- 
ease the quantity of urine and the degree 
of albuminuria will in each case indicate 
how far hydremia or h\-palbuminosis is 
responsible for the abnormal specific 
gravity. 

3. In cases of anaemia, in which there 
is no organic disease that exerts an in- 
fluence upon the specific gravity of the 
blood, this constitutes an index of im- 
provement or of progression as regards 
the anaemia. 



THE INFLUENCE OF DISEASES UPON 
THE RESPIRATORY INTERCHANGE 
OF GASES. 

To determine if disturbances involving 
the exchange of gases between the air 
and the blood, and if anomalies of tissue 
metamorphosis in conjunction with which 
the need of oxygen or the capability of 
the tissues to unite with ox3'gen may be 
altered, do in reality materially influence 
the respirator}' interchange of gases, 
Kraus and Chvostek ( Wiejier kli7i. Wo- 
chenschr., Bd. iv, 1891, p. 33) made forty 
observations in twelve persons with vari- 
ous forms of anaemia (pernicious and sec- 
ondary^ anaemia and chlorosis;, leukaemia, 
and the carcinomatous cachexia. Under 
ordinary conditions no aberration from 
the normal was observed in the gaseous 
interchange. The taking of nourishment 
invariably augmented the interchange, 
as happens also in health}^ persons dur- 
ing digestion. In a small number of 
cases muscular activity^ increased the 
combustion of oxy^gen and the production 
of carbonic acid, but not in the same 
degree as in health ; in the anaemic 
patients, the respiratory coefficient (which 
normalh' arises) was lowered. 

To determine the activity^ of the bodily 
oxidation, benzole was administered to 
six patients with diabetes, anaemia, car- 
cinoma of the stomach, and leukaemia, 
and the quantity of phenol excreted was 
measured. The proportion of phenol was 
found small in conditions of impaired 



January i6, 1892. Periscope. 



109 



nutrition, but no. special change was ob- • 
served for any single affection. 

In investigating the influence exerted 
upon the respiratory process b}- an in- 
creased volume of oxygen in the inspired 
air, an admixture of ten volumes of 
nitrogen and ninety volumes of oxygen 
was used. The subjective condition of 
healthy and ill persons was not materially 
influenced by the continuous breathing 
of such a mixture ; nor did objective 
manifestations appear. During the first 
ten minutes of easy breathing a consider- 
able increase in the comparative quantity 
of oxygen absorbed was noted ; sub- 
sequently the absorption of oxygen fell 
to the normal or lower. That this pri- 
mary increase took place in anaemic 
patients with a decided deficiency of 
haemoglobin makes it evident that the 
excess of oxygen taken up combines with 
the tissues. For a short time at the be- 
ginning of the experiment the exhalation 
of carbonic acid was increased, though 
not in the same degree as the absorption 
of oxj^gen. These observations indicate 
that there is no more substantial basis 
for the employment of oxygen in disease 
than has hitherto existed. Clinically, 
inhalations of oxygen were inefficacious. 
The most important indication for such a 
measure would be the sudden occurrence 
of respiratory insufficiency. — Amer. Jour. 
Med. Sci. 



BPIIvBPTIC AUTOMATISM. 

In a recent number of the Revue 
MHicale de la Suisse Rovtande, Dr. 
Grandjean has related a case of very 
great interest. It is that of a man of 
thirty-four, who, with the exception of 
an attack of somnambulism at the age of 
eight — an attack in which he had walked 
into his father's bedroom and congratu- 
lated him on being elected king of Italy 
— had been previously healthy. Towards 
the end of January, 1890, he began to 
suffer from nightmare and depression, 
without apparent cause, but he had no 
headache or vomiting. This condition 
persisted for two weeks. Then, on Feb. 
9th, after going to his office and working 
as usual, at nine o'clock in the morning 
he took his hat, set out on foot, and 
arrived at Pay erne, a village fifty kilo- 
metres distant. He had no recollection 
of anything that happened from the time 
he left his office until he awoke, in the 
middle of the night, in an. inn at Pa- 



yerne. His boots, he found, were much 
worn, but his clothes were in good order. 
He presented none of the usual effects of 
having passed through an epileptic 
paroxysm, except that he had a violent 
headache. After this he remained as 
usual for seven months, except that he 
had occasional "absences." Thus, on 
one occasion, while writing, he was sur- 
prised to find that he had continued at 
his work for an hour without any recol- 
lection of having done so. The work 
was done perfectly, without a single mis- 
take. At the end of the seven months 
he had another attack similar to the first, 
but lasting for two days, during which 
he had gone about to different places 
acting in a manner which did not strike 
any observer as strange or peculiar, but 
being all the time unconscious. Five 
months later he had a similar, even more 
elaborate, attack, which also lasted for 
two days, and was followed by headache 
more violent than usual. Dr. Grandjean 
comes to the conclusion that this is un- 
doubtedly a case of epileptic automatism. 
He does so from the nature of the attacks, 
from the fact that the man also suffered 
from ' ' absences ' ' of longer or shorter 
duration, really attacks of petit mat, and 
because the latter became almost totally 
suppressed under treatment by the 
bromides. The case is an important 
one, and it should serve to impress the 
fact once more that some criminals who 
profess complete unconsciousness of the 
act or acts with which they are charged 
may really be the subjects of epileptic 
automatism. If this patient had com- 
mitted some crime during one of those 
periods of unconsciousness, a defence to 
the effect that he was the subject of 
epilepsy would have been received wdth 
considerable doubt, especially as there 
was nothing in the nature of a severe fit 
to point to in the former history, but only 
those temporary ' ' absences ' ' without 
an}^^ obvious convulsion. — Lancet. 



STERILIZATION OF BRUSHES. 

These are boiled for five minutes in the 
soda solution and kept ready for use, 
floating in sublimate solution, i to 2,000 
(sublimate and acetic acid equal parts), 
with the bristles down in a small, en- 
amelled, water-tight box, devised b}'- Von 
Bergmann. In the operating-room the 
solution is changed two or three times 
daily. — Uni. Med. Mag. 



no 



Periscope. 



Vol. Ixvi 



A CONTRIBUTION TO THE PATHOLOGI- 
CAL ANATOMY OF THE RETINA AND 
OPTIC NERVE IN DISEASES OF 
THE BRAIN AND ITS MEM- 
BRANES. 

In the laboratory of Prof. Iwanski, the 
author has examined the retina and optic 
nerve in purulent basilar meningitis, 7 
cases ; tuberculous meningitis, 4 cases ; 
chronic meningitis, 12 cases ; haemorrhage 
of the brain, 7 cases ; and arterio-sclerosis 
of the brain, 9 cases, and has determined 
the following facts, viz. : 

1. All diseases of the brain and of its 
membranes in consequence of injuries 
inflicted upon them, induce pathological 
changes in the retina and optic nerve. 

2. Acute inflammation of the meninges 
occasions oedema of the papilla and dis- 
turbances which are intimately associated 
with the chief causes of this latter and 
the retina. (Neuro-retinitis oedematosa. ) 

3. Chronic inflammations of the men- 
inges produce the same condition in the 
retina. 

4. Arterio-sclerosis of the cerebral ves- 
sels extends also to the papilla and the 
retina, and always induces peripheral 
oedema in the latter. The oedema is the 
result of chronic venous hyperaemia, 
which is occasioned by disturbances in 
the circulation of the blood. 

5. When extravasation follows arterio- 
sclerosis, this phenomenon can usually 
be observed also in the vessels of the 
retina. 

6. In consequence of the pressure, 
which the accumulated mass of exuda- 
tion exerts upon the optic nerve entrance, 
choked disc (staungspapilla) very fre- 
quently results. — Falser, Deutsch. Med. 
Zeit. 

SURGERY. 



REMOVAL OF SARCOMA OF THE 
MESENTERY. 

A case has been lately recorded by 
Professor Llobet, of Buenos Ayres 
{Revue de Chirurgie, August, 1891), in 
which he removed with complete success 
a sarcomatous tumor of the mesentery, 
and at the same time resected a portion 
of the small intestine almost 5 feet in 
length. The patient, a man aged 23, 
whilst under treatment for urethral stric- 
ture, was found, quite by accident, to be 
affected with a very movable hard tumor 
of about the size of the kidney, which 
was situated within the abdominal cavity 



in the middle line, and about two inches 
below the umbilicus. The existence of 
this growth had not been previously 
suspected by the patient, who asserted 
that he had not at any time suffered from 
symptoms of disturbed digestion, or from 
pain in the abdomen. The growth was 
free from tenderness, save on forcible 
compression. In his endeavor to diagnose 
the nature of this morbid condition, the 
author was lead to reject the idea of a 
floating kidney by reason of the absence 
of urinary troubles, and of the free 
lateral mobility of the growth, and, 
guided by the facts of the situation of 
the swelling in the middle line, and of 
the absence of pain and of both general 
and local disturbance, he was disposed to 
regard it as a tumor of the mesentery. 
At the end of 1890 laparotomy was per- 
formed for the removal of the growth. 
A globular tumor was exposed involving 
both layers of the mesentery, and covered 
in front by a long loop of small intes- 
tine. The portion of mesentery between 
the tumor and the intestine was traversed 
by numerous large blood vessels. It was 
thought to be necessary to remove with 
the tumor the portion of small intestine 
adhering to its anterior surface. Its re- 
tention in the abdominal cavity after dis- 
section from the tumor would, it is held, 
have exposed the patient to the almost 
certain danger of relapse and of wide 
and general diffusion of' the disease, and, 
moreover, the retained portion of intes- 
tine would very probably have become 
gangrenous as a result of removal of the 
corresponding portion of mesentery, and 
of arrest of the vascular supply. After 
a thick ligature of catgut had been 
applied to the portion of mesentery 
attached to the tumor, the fixed portion 
of intestine, the length of which meas- 
ured one metre and a half, was resected, 
and the two open ends of the divided in- 
testine were brought together by sutures 
arranged in two layers, one set being 
carried through the mucous coat, and the 
other set through the muscular and ser- 
u s coats. The tumor was then excised 
by means of curved scissors, the bleeding 
being arrested by the application of the 
thermocautery. The operation, which 
was performed with strict attention to all 
antiseptic precautions, lasted two hours 
and a half. The patient, who was able 
to get up and sit in a chair on the 
fifteenth day from the date of the opera- 
tion, made a good recovery. The resected 



January i6, 1892. 



Periscope, 



1 1 1 



portion of intestine which had been taken 
from the distal part of the ileum con- 
tained a round worm. No description is 
given in this paper of the minute struc- 
ture of the growth. Professor Llobet 
draws from the facts of the case the fol- 
lowing conclusions: (i) Whenever a 
diagnosis has been made of sarcoma or 
fibro-sarcoma of the mesentery, the sur- 
geon, unless the growth has attained 
very great dimensions, should resort to 
extirpation ; (2) the operation should be 
performed as soon as possible, and before 
the tumor has become very large ; it is 
then less serious, and there is less proba- 
bility of subsequent generalization of the 
disease and of its local recurrence ; (3) 
in cases in which the diagnosis is doubt- 
ful, the surgeon should perform an ex- 
ploratory laparotomy ; (4) if the intestine 
be found adherent, even over a consider- 
able extent, there should be no hesitation 
in performing enterectomy ; (5) resection 
of a considerable length of small intes- 
tine is attended with the less risk the 
further the resected portion of intestine 
is away from the stomach. — Brit. Med. 
Jour. 



RADICAL CURE FOR OZ^NA. 

Dr. Michel Christovitch, of Salonique, 
says that ozaena is considered as an in- 
curable disease, simply because its treat- 
ment was exclusively symptomatic, 
struggling against the stagnation and 
fetidnCvSS of matters by means of irrigations, 
of antiseptic pulverizations, etc, , . . . the 
disease being considered as originating 
from a strumous or specific constitutional 
general state. 

It was only three years ago that the 
French Society of Laryngology, in Paris, 
discussed at length the nature of ozaena, 
and came to the conclusion that it is 
merely local and of a microbian origin. 

Hajet has found, in the secretions of 
ozaena, a coccus very similiar to the cap- 
sulated coccus of Friedlander. That 
bacillus decomposes organic matters ; 
then fatty acids are developed, producing 
the fetidness characteristic of ozaena. The 
microbe resides in the glands of the nasal 
mucous membrane, which are media 
propitious for the culture of that micro- 
organism. 

Ozaena, therefore, may be cured when 
the glands of the nasal mucous membrane 
disappear, either by the effects of the dis- 
ease itself, or through an operation. 



Ozaena is only the characteristic 
symptom of the disease called chronic 
atrophic rhinitis. 

That atrophic rhinitis will develop 
better with a person of a weak or strumous 
constitution, but well constituted in- 
dividuals are not exempt. 

Basing myself on the anatomo-patho- 
logical lesions, I find that the most 
rational treatment is by destroying the 
focuses of microbes— that is, the degener- 
ated mucous glands — and, according to 
the more or less advanced state of the 
affection the surgical treatment shall be 
more or less energetic. At the start of 
the affection we should limit ourselves to 
the cauterization of the deep and superior 
parts of the nostrils with the galvano- 
cautery, and repeat it according to circum- 
stances. When the lesions of the atrophic 
rhinitis are already advanced, it is abso- 
lutely necessary to practice the real 
operation in destroying, by removal, all 
the degenerated mucous glands covering 
the nares interncE up to the naso- 
pharyngeal region. Then, in order to 
complete the operation, we cauterize with 
the galvano-cautery. 

Process of Operating. — On the day pre- 
ceding the operation we make abundant 
alkaline and antiseptic irrigations of the 
nostrils, which means are insufficient for 
a complete antisepsy and for removing 
the concrete matters, which are very ad- 
hesive, especially toward the superior 
anfractuosities. We render the field of 
operation less sensitive, by means of pads 
of hydrophile cotton dipped in a concen- 
trated solution of cocaine, which are in- 
troduded high enough and deeply. 

After ten minutes, we withdraw the 
pads, and we proceed with the operation. 
With a scraper elongated and of small 
dimension, so that it may be easily intro- 
duced, even into the small anfractuosities, 
we scrape and empty effectually and 
rapidly all the degenerated nasal mucous 
membrane covered with concrete masses, 
even to the naso-pharyngeal region, and 
we continue scraping in this way until 
the fetidness has completely disappeared. 
After the scraping we immediately make 
the cauterization of the profound parts 
that have escaped scraping. The haemor- 
rhage, that is considerable, stops rapidly 
by the introduction, into the nostrils, of 
the pads of hydrophile cotton in a large 
quantity. 

One single operation well made sufiices, 
in most cases, for the complete cure. 



I 12 



Periscope. 



Vol. Ixvi 



That operation presents no incon- 
venience, except some pains in the ears. 

In one case, the consecutive treatment 
consisted simpl}^ in snuffing powder of 
iodoform mingled with powder of boric 
acid. 

In conclusion, the efficacious treatment 
should be local and, in the second place, 
general. Ozaena should be treated early, 
not only in order to stop the progress of 
the affection, but also in order to prevent 
the very grievous consequences resulting 
from the continual inspiration of the nasal 
putrid matters. 



THE SEAT OF PUNCTURE IN PARACEN- 
TESIS ABDOMINIS. 

Trzebicky (^Archiv. fiirklin. Chir.^ xli., 
4), in performing paracentesis abdominis 
at the point of election — that is, midway 
between the umbilicus and the anterior su- 
perior spine of the ilium — wounded a large 
blood-vessel which gave such trouble- 
some bleeding that the life of the patient 
w^as threatened. The haemorrhage was 
arrested by compression of the common 
iliac artery. Incited by this experience, 
and by several reports of fatal bleeding 
following puncture at this point, Trze- 
bicky conducted an experimental research 
upon a large number of cadavers. As a 
result of this he announces the following 
conclusions : 

In the majority of cases paracentesis 
performed at a point midway between the 
umbilicus and the anterior superior spin- 
ous process of the ilium is perfectly safe, 
since neither the epigastric arter}^ nor an}^ 
large branch of this vessel is liable to be 
wounded. The artery commonly crosses 
this line at the junction of the inner with 
the middle third. 

In a certain proportion of cases, how- 
ever, the epigastric artery or one of its 
branches lies directl}^ beneath the point of 
election. 

The course of the epigastric arter}^ is 
seldom exactly similar in the two sides 
of the body. 

Since the arterj^ runs within the sheath 
of the rectus muscle, its course depends 
mainly upon the position of this muscle. 
In case the two recti are separated by ab- 
dominal distention, the artery is displaced, 
so that it lies very near the point of elec- 
tion for puncture. The rectus muscle 
does not, however, bear a constant rela- 
tion to the artery. At times, even though 
the muscle is displaced to the side, the 
artery lies near the middle line. 



Variations in the origin of the epigas- 
tric artery seem to have no influence on 
the course of the former vessel. 

The artery is usuall}^ accompanied by a 
single vein. 

Paracentesis abdominis should be per- 
formed either in the linea alba or in the 
outer half of the line joining the umbili- 
cus and anterior superior iliac spine. In 
case the linea alba is selected, it is not 
important to keep strictly in the middle 
line, since there is an arterial branch 
which may be wounded if the trocar is 
entered, even slightly, to one side. — Am, 
Jour, of the Medical Science. 

OBSTETRICS. 



THE TREATMENT OF ALBUMINURIA 
AND NEPHRITIS IN PREGNANCY. 

Mijulieff {Geneesk. Cour., i8qi, No. 
18) has derived the following indications 
for treatment from three cases of neph- 
ritis in pregnane}^ in which the foetus 
perished in the uterus : when a woman 
previoush' healthy shows symptoms of 
nephritis during the first months of preg- 
nancy, abortion should be induced ; 
in the second half of pregnane}^ it is 
rarel}" necessary to interrupt pregnancy, 
except for urgent symptoms. In chronic 
nephritis during pregnancy, labor should 
be induced in the interest of mother and 
child as soon as viability is possible. 



OPIUM ENEMATA IN THREATENED 
ABORTION. 

In the Gazeta Lakarsks, No. 33. 1891, 
p. 657, Mr. Feliks Arnstein, of Kutno, 
Russian Poland, maintains that in case 
of threatened abortion the practitioner is 
justified in accelerating and terminating 
the process only when the interruption 
of gestation is induced by death of the 
foetus. "In all these cases" he says, 
' ' be the. uterine pains of short or long 
standing, weak or strong ; be flooding 
absent or present, scanty or profuse ; be 
the cervix softened or not, and the os 
closed or w^idely gaping — in all alike 
treatment must consist in adopting all 
possible measures for retaining the ovum 
in the womb and arresting its threatened 
expulsion therefrom." As far as the 
writer's personal experience goes, the best 
way to accomplish this is the persevering 
administration of opium per rechnn. As 
much as 15 drops of simple tincture of 
opium, Ph. Ross, (containing i in 10 of 
the drug) with 2 tablespoonfuls of luke- 
warm water should be injected into 



January i6, 1892. 



Periscope. 



the bowel every hour, the patient lying 
quietly in bed and taking occasionally 
some acid drink. Leaving out of con- 
sideration cases in which complete de- 
tachment of the ovum has already taken 
place, the treatment is said to be followed 
by the best possible results : ' ' the uterine 
pains steadily and fairly quickly become 
less intense and less frequent, and ulti- 
mately cease altogether ; hemorrhage 
becomes less and disappears ; in some 
(occasion all}^ twenty) hours the os is found 
to have contracted and the ovum to have 
receded. ' ' The author relates a case in 
which a fairly advanced abortion was 
controlled by the injection of 45 drops of 
the opium tincture. In some cases, 
however, the total quantity required 
for the purpose may amount to 80 or 
over 100 drops. Pregnant women are 
thought to tolerate opium much better 
than other persons, the toxic effects 
being usually limited to a heavy feeling 
about the head, and drowsiness, which 
disappear in a day or so. — British Med. 
founial. 

OBSTETRICAL PARAIvYSBS IN THE 
NEWBORN. 

Dr. Danchez {Annales de Gynec. et 
d'Obstet., October, 1891 j concludes a 
series of observations upon injuries to 
the child during labor, and their more 
or less permanent effects. A number of 
instructive cases have beed collected and 
published in abstract in Dr. Danchez' s 
memoir. In several, pressure on Krb's 
point (where the fifth or sixth cervical 
nerves emerge) caused more or less par- 
alysis of the deltoid, brachialis anticus, 
biceps, and supinator longus. This pres- 
sure is made by the obstetrician's fingers 
during version, aiid traction on the 
shoulders during extraction in breech 
cases, and in normal presentations where 
the second stage is lingering. Some- 
times the serratus magnus is paral5^sed. 
The forceps may do as much harm as the 
fingers. A bad case of dislocation of 
the shoulders and paralysis, under Dr. 
Monnier's care, is published for the first 
time by Dr. Danchez. A country mid- 
wife undertook a breech case. In order 
to hasten delivery she dragged the child's 
body forcibly by the feet. The arms 
were thus pulled over the head. Next 
day it was noticed that the child's arms 
were abducted and rotated inwards. When 
the child was seen four years later by Dr. 
Monnier the arms remained in that posi- 



tion. When it was eleven days old a 
physician at Quimperle diagnosed dis- 
location of both shoulders, but did not, 
apparently, attempt to reduce them. 
Electricity was tried for six months by 
another practitioner. When examined 
by Dr. Monnier the dislocations were 
evident. All the muscles of the shoulder 
were atrophied ; the teres minor and in- 
fraspinatus formed a firm cord. The 
child could hardly use his hands. He 
was a male in good general health. Sen- 
sibility was intact all over the damaged 
upper extremities. Dr. Danchez distin- 
guished two classes of congenital obstet- 
rical paralyses. The first class includes 
the so-called spontaneous paralyses, when 
the lesion is entirely due to the natural or 
abnormal mechanism of labor, and not 
to the obstetrician or his instruments. 
The head or one of the limbs is pressed 
against the surrounding parts to the 
damage of certain nerves. The second 
variety bears the term " traumatic paraly- 
sis," where during traction, version, or 
the use of the forceps, some damage is 
done to a nerve or to a plexus of nerves. 
Over and above these two classes Dr. 
Danchez adds a third, which he terms 
"obstetrical pesudo-paralysis," where 
the paralysis is simulated by primary or 
secondary dislocation of one or both 
upper extremities, as in Dr. Monnier's 
case. Obstetrical paralyses are almost 
entirely motor. Nevertheless, two cases 
are recorded where sensory paralysis fol- 
lowed difi&cult version ; the serratus 
magnus and many muscles in the arm 
were, in both instances, paralyzed. — 
British Med. Journal. 



PILOCARPINE IN PUERPERAL 
ECLAMPSIA. 

In the Gazette hebdomadaire des sciences 
medicates for September 12, Dr. Strisover 
adds to the experience of observers in 
this field the results of his use of pilo- 
carpine in the treatment of eclampsia. 
By the subcutaneous injection of hydro- 
chloride of pilocarpine the author has been 
successful in controlling the convulsions 
and preventing their recurrence in ten 
cases. The treating successively of such 
a number of cases without one death has 
led the author to the conclusion that 
pilocarpine is an antagonist to the 
eclamptic process ; that feebleness of the 
pulse is not a contra- indication to the 
repeated injection of the drug, so long 



Periscope, 



Vol. Ixvi 



as the convulsions reappear ; and, finally, 
that the condition of the pupils is to be 
relied upon as an index to the further 
accession of the convulsions or to im- 
munity by the physiological action of the 
drug. 

GYNECOLOGY. 



HYDATIDS IN THE PBLVIS SIMULAT- 
ING OVARIAN TUMOR. 

Dr. Olenin {Nouvelles Arch, d' Obstet. 
et de Gynec, Supplement, September, 
1891, p. 426) read before a Russian 
Medical Society a remarkable case of 
erroneous diagnosis. A multipara, aged 
43, had a swelling with pain in the hypo- 
gastrium for two years. Abdominal 
section was performed and no ovarian 
tumor could be found, but innumerable 
hydatid cysts were disseminated in the 
usual manner over the omentum, and 
also in the substance of the liver. The 
largest of all the hydatids, a cyst as big 
as a child's head, was situated in the 
pelvis. The patient died of peritonitis 
on the day after operation. — Brit. Med. 
Jour. 



THE DIAGNOSIS OF CHANCRES OF THE 
CERVIX. 

According to Rasumow {Moskau, 1890) 
in the primary affection of the cervix 
appears in two varieties — as erosive and 
ulcerative, and deep chancres having 
sharply defined borders. The author 
claims that the diagnosis of primary 
syphilitic affection of the portio vaginalis 
is not as difiicult as is claimed by most 
gynaecologists. It is made evident by the 
presence of indolent, hard, and immov- 
able glands in the inguinal region. Soft 
ulcers of the cervix may often be over- 
looked, being painless and manifesting 
no symptoms. Rarely an inguinal bubo 
develops in connection with a soft chancre 
of the portio vaginalis. 



DANGER OF CAUTERIZATION OF THE 
CERVIX AND UTERUS. 

Dr. R. Pichevin {Nouv. Arch, d' Obstet. 
et de Gynec, February to August, 1891) 
has published a valuable series of cases, 
collected from numerous sources, which 
show the danger of lavish and careless 
use of caustics — a danger common to all 
the resources of ' ' minor gynaecology ' ' 
when employed in an unintelligent 



manner. Dr. Pichevin refers chiefly to 
mineral caustics, such as chloride of 
zinc in sticks, pate de Canquoin, and nitrate 
of silver. The latter is by no means 
harmless. Dr. Walton describes three 
cases where complete atresia of the cervix 
with amenorrhoea followed the applica- 
tion of sticks of nitrate of silver to the 
interior of the uterus. Forcible dilatation 
of the cer\dx was found necessary. In 
other cases disease of the appendages fol- 
lowed frequent cauterization. — Brit. 
Med. Jour. 

TOTAL EXTIRPATION OF THE UTERUS. 

Kattenbach has totally removed the 
uterus 57 times — 53 times for carcinoma, 
twice for sarcoma, twice for prolapsus. 
He finds that total extirpation is always 
indicated when the technique of the oper- 
ation can be easily executed. He even 
hopes to attain a complete cure. Theo- 
retically, partial extirpation may be excel- 
lent and sufficient, but practically, it is 
very rarely indicated. For example, he 
partially removed the uterus of a woman 
seven months pregnant, upon the an- 
terior lip of which he found a carcino- 
matous growth as large as a walnut. 
He removed it by a triangular incision, 
and the pregnancy continued its normal 
course. Generally speaking, he is of the 
opinion that whenever it is necessary to 
extend the operation beyond the vaginal 
insertion entire removal of the organ is 
to be preferred, as there is much greater 
danger of relapse in cases of partial re- 
section. Of the 57 cases of total extir- 
pation only 2 died. One of these deaths 
was caused by uraemia from ligature of 
the left ureter, and also, perhaps, by an 
injury to the bladder. One of the dangers 
of the operation is the possible wounding 
of the ureters or the bladder. In two 
cases he was afterwards obliged to per- 
form colpocleisis, on account of vesico- 
vaginal fistula. Three of the women in 
question were over 60 years of age, and 
grave pulmonary affections afterwards 
supervened ; but they had previously 
suffered from bronchitis, emphysema and 
cardiac weakness. He attaches great im- 
portance to the suture of the peritoneum 
and to means of disinfection, and prefers 
solutions of boric and salicylic acid. As 
to the danger of relapse, a year had 
passed away without the reappearance of 
the disease, in 25 of the cases of car- 
cinoma, and a still longer period in 7 
others. All the patients recovered 



January i6, 1892. 



Periscope, 



promptly after the operation. In case of 
relapse, subsequent treatment is by the 
use of Paquelin's cautery and chloride of 
zinc. He never had abundant haemor- 
rhage. One patient was cured of a car- 
cinomatous fistula of the bladder by the 
operation. As a whole the results of 
his work encourage total extirpation of 
the uterus, especiall)^ when it can be per- 
formed at a favorable m.om^r\.\..— Journal 
de Medecine de Paris, Sept. 20, .1891. 



LAPAROTOMY IN PERITONITIS. 

Dr. Krecke, of Munich, has collected 
from various sources the results of laparo- 
tomy in diffuse purulent peritonitis, and 
points out that the operation has been the 
means of saving many lives ; for, although 
the statistics of peritonitis treated medi- 
cally show a mortality considerably below 
that given by laparotomy, it is clear, as 
he says, that a large majority of the suc- 
cessful cases in the first category are such 
as would never be submitted to surgical 
treatment, many of them being referable 
to inflammatory lesions of the female 
pelvic organs, and not of an infective 
kind. Surgical intervention is, on the 
other hand, called for in case of general 
infective peritonitis, such as arises from 
perforation or in the puerperal period, or 
from extension of suppuration from other 
parts. Dr. Krecke points out the difii- 
culties of securing effective drainage, and 
is averse to irrigation, owing to the 
possibility of its disseminating septic 
material to parts of the membrane not 
previously infected, or of exciting hem- 
orrhage. He prefers rather a simple in- 
cision, drainage, and the use of iodo- 
form gauze. Peritonitis is fatal from 
septicaemia, due to the absorption of 
poison from the cavity ; but it is remark- 
able how tolerant the membrane may be 
of such virus. If the limit of this toler- 
ance could be gauged, some guidance 
might be obtained as to the appropriate- 
ness of surgical interference in any case. 
But the fact is that there are various de- 
grees and forms of acute peritonitis, some 
being fatal from sceptic absorption within 
a few hours of the onset, before even any 
noticeable change takes place in the mem- 
brane itself. Karly operation is then 
called for, and consideration must also be 
had to the source of the inflammation. 
Dr. Krecke' s statistics are interesting and 
instructive. He has collected 119 cases 
of laparotomy in general peritonitis, the 
origin of which was determined in all but 



18, of which 9 were successfully treated 
by laparotomy and 9 died. The majority 
of the remaining 10 1 cases belonged to 
the category of perforation peritonitis. 
Of these, 36 were cases of general peri- 
tonitis following perforation of the ver- 
miform appendix ; 12 were cases of 
typhoid perforation (a condition which at 
first sight it might seem hopeless to deal 
with), and these yielded 5 successes ; 12 
were due to perforation from gangrene 
and other causes implicating the bowels 
— of the gangrenous not one recovered, 
and of the 8 others only 3 were cured by 
the operation. No case of perforating 
ulcer of the stomach has yet been saved 
by laparotomy — a result precisely the 
same as that yielded by medical treat- 
ment. Of traumatic cases, 3 of punc- 
tured wounds and i of gunshot were re- 
covered ; but of contusions, only 3 out 
of 8 cases recovered from laparotomy. 
The measure, however, saved 5 out of 13 
cases of puerperal peritonitis. Lastly, a 
group of cases of peritonitis from various 
other causes gave 3 deaths and 6 recov- 
eries. The total result is 119 cases of 
general peritonitis treated by laparotomy, 
51 recoveries, and 68 deaths — statistics 
which are certainly encouraging. — 
Lancet. 



HYGIENE. 



SOME COMMON ERRORS IN THE FEED- 
ING OF YOUNG CHILDREN. 

In a recent lecture reported in the 
Practitioner for July, Dr. Cheadle draws 
attention to certain points in the feeding 
of infants in regard to which faultj^ and 
injurious practices prevail. One of the 
most frequent sources of disaster is the 
sudden weaning with the use of fresh 
cows' milk and water. The massive 
curds formed from cows' milk are fre- 
quently beyond the feeble digestive 
powers of the infant. Dilution will par- 
tially remedy the matter, but cannot, as 
a rule, be carried to a sufficient extent 
without unduly increasing the bulk of 
the food. The clots, by decomposing, 
cause colic, vomiting and diarrhoea. 
Boiled milk not only is to a certain de- 
gree sterilized, but clots less firmly than 
raw milk. Children should be weaned 
on boiled milk and barley water. In the 
case of very young or delicate children, 
however, the milk should always be pep- 
tonized at first, a proper degree of dilu- 
tion being observed at the same time. 



Ireriscope. 



\o\. Ixvi 



There is danger here of another grave 
error — the prolonged use of artificially- 
digested foods. While these preparations 
do excellent service in the case of children 
just weaned or with small digestive 
power, they are not proper for continued 
use. The power of digesting casein be- 
comes gradually less, nutrition is im- 
paired, and the child tends to become 
flabby, anaemic and soft in bone. Still 
another error consists in the furnishing 
of an insufiicient gross amount of nutri- 
tive material. A child may be unable to 
digest a mixture of milk unless highly 
diluted, but the capacity of the stomach 
being limited, it may be impossible for it 
to take a sufiicient quantity of such a 
mixture to supply the material required 
for growth and nutrition. The difiiculty 
may be overcome by the addition of 
cream or some good preparation of meat 
juice, the quantity of milk being in- 
creased as the digestive power develops. 
Food ' deficient in fat, as well as that 
deficient in protein, is certain to cause 
trouble. Fat especially is of great im- 
portance in the food of young children. 
Those deprived of these two elements are 
often large and fat, but flabby, anaemic 
and rachitic ; yet most of the artificial 
foods upon which children are so largely 
fed are almost wholly lacking in fat and 
to a less degree in proteids. The presence 
of an antiscorbutic element in the food is 
also a matter of prime importance. Fresh 
milk contains the element in sufficient 
quantity, but all farinaceous foods, and 
all the dry artificial foods, are decidedly 
deficient in this regard. They require 
the addition of some fresh element to 
supply the antiscorbutic quality. — N. Y. 
Med. Jour. 



VKGETABIvB BUTTER. 

F. Jean states that an alimentary fat 
has been manufactured at Mannheim 
from the oils of the kernel of the 
cocoanut {Cocos mtciferd). A hectare of 
cocoa palms, representing 225 trees, yields 
yearly 800 kg. of oil. Hitherto the use 
of these oils has been hindered by their 
acrid flavor ; but by treatment with alcohol 
and animal charcoal the rancid flavor is 
removed and the product is rendered 
white. This is the only fat which is 
analagous to the cow' s butter, as it con- 
tains the same proportion of soluble fats. 
It has the advantage of containing no 
pathogenic germs. 



HOW TO JUDGE THE QUALITY OF 
CONDENSED MILK. 

The general appearance when poured 
from a spoon should be glossy ; the more 
glossy the better. It should be ropy or 
stringy like very heavy S3^rup. 

The color should be that of cream, but 
the color varies according to the season 
of the year in which the milk is con- 
densed, the same as milk not condensed 
varies in color. Milk is more yellow in 
summer, when cows are on pasture, than 
in winter, when they are fed on dry hay. 

Thickness varies with age. Thicken- 
ing by age is natural to condensed milk ; 
rapid thickening only proves that the 
milk is preserv'cd in the best manner, and 
that it retains in the highest degree the 
characteristics of milk in its natural state. 
Condensed milk which does not thicken 
by age, or which thickens very slowly, is 
milk abused in the process of condensing. 
Consumers make a great mistake in sup- 
posing that the thinnest condensed milk 
is the best. The thinnest condensed 
milk contains the most water, and, of 
course, less of milk solids or nutritives. 
The thickest condensed milk, if in sound 
condition, is the most valuable. There 
is a degree of thickness, however, that 
is inconvenient. If condensed milk is so 
thick that it will not run out when an 
open can is inverted, it is troublesome to 
dissolve. If it is not actuall}^ hard, very 
little stirring in the can will render it 
sufficiently liquid for convenient use. 

Condensed milk, if properly done, does 
not destroy cream globules, but leaves 
the constituents of milk unaltered and 
natural. One method, therefore, of de- 
termining the relative quality of difierent 
samples of condensed milk is to ascertain 
the amount of butter that can be made 
from each. — Scientific American, 



ALCOHOL AND THE NERVOUS SYSTEM. 

In the inaugural dissertation of Dr. 
Spaink, of Baarn, of which a short ab- 
stract appears in the Neurologisches Cen- 
tralblatt, an account is given of the results 
of certain experiments carried out with 
the view of testing the effect of alcohol 
on the peripheral nervous mechanism of 
rabbits. Clinically, it was found that the 
animals lost weight, became dull and 
weak, had tremor of tongue and shaking 
all over, and finally lapsed into a condi- 
tion closely resembling delirium tremens. 
In the peripheral nerves examined there 



January i6, 1892. 



Periscope. 



117 



was found to be the usual degeneration 
of the medullary sheath, but there was 
also present a curious corkscrew or even 
knotted appearance of the axis cylinders, 
which does not seem to have been pre- 
viously described. The author regards 
the appearance as pathological, and not 
due to the methods of hardening or stain- 
ing. — Lancet. 



PEDIATRICS. 

NOCTURNAI. ENURESIS IN MOUTH- 
BREATHERS. 

Dr. Otto Koerner says that a very 
common cause of enuresis in children is 
the habit of mouth-breathing, and reports 
some cases in support of this view in the 
Centralblatt fur Klinische Medicm for June 
6, 1 89 1, In every case of wetting of the 
bed by children, the physician, he says, 
ought to examine the little patient care- 
fully to see whether there is any obstruc- 
tion in the upper respiratory passages, 
and even if none be found the child 
shoidd be observed when sleeping to see 
if it is not breathing through the mouth. 



RAISING CHILDREN IN BRAN. 
This method was proposed by M. Pue 
at the Sodete Normande d"" Hygiene Pra- 
iique. It consists of a cradle which has 
the wooden bottom taken out, and is then 
lined with a strong cloth. In this is 
placed sterilized bran to nearly half a 
yard in depth. A hair pillow is used. 
The baby has only a short flannel shirt 
on and is naked from the navel down- 
ward. It is covered with a woolen 
blanket, and a wool-lined dress is kept to 
put it in when taken up for nursing. It 
has thus full liberty of movement in all 
its limbs, while its dejections pass at once 
into the pure bran, keeping the child dry 
and clean, even if there is diarrhoea. This 
method is a cheap one, the bran not cost- 
ing as much as diapers. 



INTUBATION IN CROUP. 
Bscherish {^Rev. Mens, des Mai. de 
VE^if., April, 1 891), after discussing 
the advantages and disadvantages of 
tracheotomy and intubation, and com- 
paring the statistics of the two operations, 
arrives at the following conclusions : 

1. Intubation cannot completely take 
the place of tracheotomy ; in cases in 
which one can choose between the two, 
the interests of the patient will usually 
demand tracheotomy. 

2. The value of intubation cannot be 



determined from statistics. Each case 
should be studied with reference to its 
own characteristics and the localization 
of the disease. 

3. The advantages of intubation are the 
ease and rapidity with which it can be 
done, the ability to dispense with anaes- 
thesia and skilled assistants, absence of 
an external wound, and short duration of 
treatment. The disadvantages are necro- 
sis from compression of the laryngeal 
mucous membrane, frequent entrance of 
food into the respiratory passage, frequent 
and painful attacks of cough, difficult 
expectoration of membranes and secre- 
tions, and deficient pulmonary ventila- 
tion, as compared with tracheotomy. 

4. Tracheotomy should be preferred to 
intubation when the diphtheritic process 
is rapidly extending to the bronchi or 
involves them from the beginning, when 
the patients are very young and the mus- 
cles of expiration only slightly developed, 
when the disease has a septic character or 
has followed some other debilitating 
disease. 

5. Intubation is indicated in cases in 
which the process is limited to the 
pharynx and larynx and does not show 
any septic characteristics. 

6. If at the end of five days it is still 
improper to remove a tube which has 
been introduced, if alimentation becomes 
difficult and there is a probability that 
the disease has extended to the bronchi, 
the tube should be removed and tracheo- 
tomy should be performed. 



THE MORPHOLOGY OF BREAST MILK 
AND THE NUTRITION OF THE 
CHILD. 

An extensive study by Ivanoff ( TK^se 
de Sai7it Petersburg, 1890) of this subject 
led him to the following conclusions : 

1. The cellules of colostrum are of 
epithelial origin. 

2. The multiparse colostrum changes 
to milk more rapidly than in primiparse. 

3. Puerperal diseases retard the disap- 
pearance of the colostrum corpuscles. 

4. These corpuscles reappear in the 
milk after ten months of lactation, and 
when the infant is only partly fed from 
the breast. 

5. The free hyaline corpuscles, as well 
as those which are enclosed in the fatty 
globules, form a constituent of normal 
milk at a certain period of secretion. 

6. Good health, good nutrition, and 
youth in the mother, give a milk richest 



ii8 



Periscope. 



Vol Ixvi 



in fatty globules of large size, as is also 
true of the cellules. 

7. The last portion of milk taken at a 
feeding holds fewer globules, and these 
of smaller size than the first portions. 

8. The estimation of the nutritive 
quality of milk should be based upon the 
number of fatty globules ; and, second- 
arily, upon their size, the quantity of 
cellular element, and, finally, upon the. 
quantity of granules. 

9. Milk which contains a very large 
number of fatty globules (more than 3^ 
per cent. ) is not well borne by very young 
infants. 

10. Milk, the globules of which are 
large, is less nutritive and less well borne. 

1 1 . The maximum of dail}^ increase of 
weight of the child is produced by milk 
which contains a mean quantity of fatty 
globules of medium size (27.7 grammes 
daily). 

12. The milk which contains few fatty 
globules gives little increase of weight 
(16 grammes daily) ; and the same is true 
if the fatty globules are in too great 
quantity or are too large (19 grammes 
daily). 

13. Women who are thin and young in 
general are the poorest nurses, often 
making the children dyspeptic and giving 
them a mean daily increase of weight of 
only 1 1.5 grammes. 

14. The microscopic examination of a 
freshly secreted milk give a sure indica- 
tion of its nutritive value. 



MEDICAL CHEMISTRY. 



REAGENT FOR ACETONE. 

Prof. Alf. Schwicker communicates a 
new method of detecting acetone to the 
Chemiker Zeihtng (No. 52). 

He found that a mixture of acetone 
and aqueous ammonia dissolves powdered 
iodine with evolution of heat. The liquid 
becomes turbid, and after a time separates 
iodoform. At the same time there is pro- 
duced an irritating odor, causing tears in 
the eyes, which is probably due to iodine 
substitution compounds of acetone. No 
gas is given off, and the liquid is found to 
contain acetic acid. 

This reaction may be used to detect 
acetone, for even traces of the latter dis- 
solved in water respond to it. Moreover, 
alcohol does oiot produce iodoform under 
the same circumstances. 

The best way to execute the test is as 
follows : 



To the solution containing or supposed 
to contain acetone add a few drops of 
strong ammonia, and then i or 2 drops of 
a decinormal iodine solution. 

This will cause a blackish cloud of 
iodide of nitrogen, which disappears on 
shaking or gentl}^ warming, and soon 
makes place to a 3^ellowish cloud of iodo- 
form if the liquid was not too diluted. 
By adding i or 2 drops more of the iodine 
solution, the amount of iodoform ma}^ be 
increased. After every new addition of 
iodine, and disappearance of the black 
cloud by shaking, a few moments are al- 
lowed to elapse. On shaking, the odor 
of iodoform will be distinguishable in 
spite of the ammonia. 

In the case of a x^ry dilute solution of 
acetone a more dilute iodine solution must 
be used. 

Should the black iodide of nitrogen 
not disappear, but remain, it ma}' be de- 
composed \>y the cautious addition of 
hj^posulphite of sodium. 

Solutions of acetone of i in 5000 3'ield 
a precipitate of iodoform after a few min- 
utes, or at least exhibit a decided odor of 
iodoform. 

Alcohol, as alread}^ stated, does not re- 
spond to this reaction, but aldeh3'de does. 
In this case iodoform is also produced, 
but the acid generated as a secondary' pro- 
duct must in this case be formic acid. 



SCOPOLAMINE. 

Prof. Ernst Schmidt has recently given, 
at a meeting of German Naturalists and 
Physicians, some further particulars of 
an alkaloid separated by him from the 
root of Scopola atropoides some eighteen 
months ago, and provisionally named, 
scopolamine. The hydrobromide occurs 
in beautiful glassy crs'stals, and from the 
results of analyses of this salt and the 
hydrochloride, hydriodide, sulphate, and 
a highly characteristic gold salt, as well 
as of the free base, the composition of sco- 
polamine is represented by the formula 
C1TH21NO4. Scopolamine appears to con- 
tain a hydroxyl group, as it yields a 
monoacetyl derivative ; towards nitrous 
acid it behaves as a tertiary base. By boil- 
ing with bar3^ta water it is split up into 
atropic acid and a crystalline base, melt- 
ing at 110° C, which has a composition 
represented by the formula CgHsOi. 
Professor Schmidt announced that the 
' ' hyoscinum hydrobromicum ' ' at present 
met with in commerce consists essentially 



January i6, 1892. Clippings and News Items. 



119 



of scopolamine hydrobromide. Scopola- 
mine is said to have also been obtained in 
small quantity from belladonna root and 
from stramonium seed. The mydriatic 
basic substance separated by the author 
from one sample of Duboisia myoporoides 
consisted essentially of scopolamine, but 
that obtained from a sample of the leaves 
from another source was essentially hyos- 
cyamine. 



CLIPPINGS AND NEWS ITEMS. 



CIvASS BANQUET. 

The "class of '78 " of Jefferson Medi- 
cal College held its fourth annual banquet 
at the Hotel Bellevue, December 29, 1891. 
The invited guests were Professors Da 
Costa and W. H. Pancoast, the two living 
professors of the faculty of 1878, and Dr. 
T. H. Andrews, with Dr. Webster 
Fox, class president, in the chair. 

Among those present were Drs. Daniel 
B. Hughes, A. H. Hulshizer, Dr. Frantz, 
J. Moore Campbell, T. K. Conard, M. 
John Cummings, Nevin B. Shade, Lam- 
bert Ott, Harry Braus, H. Howard 
Drake, J. A. Wamsley, Dr. Arney, H. 
Page Haugh, Fred. A. Oliver, F. H. 
Carrier and J. W. Sampsel. 

The next banquet will be held in Phil- 
adelphia, November 10, 1892. 



AMERICAN PHARMACEUTICAL AS- 
SOCIATION. 

Membership in the American Pharma- 
ceutical Association is obtained only by 
election at the annual meeting. ' ' Every 
pharmacist and druggist of good moral 
and professional standing, whether in 
business on his own account, retired from 
business, or employed by another, and 
those teachers of pharmacy, chemistry, 
and botany who may be specially 
interested in pharmacy and Materia 
Medica," are eligible for membership. 
For blank applications and further in- 
formation address, Dr. H. M. Whelpley, 
2729 Washington Avenue, St. Louis, 
Mo., Chairman of Committee on Mem- 
bership. 



DR. LUCIA REDDING THOMPSON. 

Dr. Thompson, one of our recent 
French correspondents, has returned to 
this city and will open a Sanitorium. 



THE SONG OF THE SADDLE-BAGS. 

BY H. C, S. 

Faded and rusty, mud-spattered and worn, 

Eifled of contents, bottles broken and gone, 

Covered with dust, I hang here and mourn 

For the days of yore ; 

When the world bowed down to me, 

As I sang this song exultingly : — 

" Now and forever, the whole round world wags, 

To the rhythmic song of the saddle-bags I " 

In palace and cottage, at sea or ashore, 

'Mid sunshine or storm, I continued to pour 

Forth my treasures of healing frail man to restore 

To comfort and health. 

Eequiring no thanks, accepting no fee, 

Again and again I sang joyously : — 

" Now and forever, the whole round world wags, 

To the rhythmic song of the saddle-bags ! " 

Like Napoleon I sigh'd, " the world is small ! " 
I longed for new races — to conquer them all. 
I laughed when 'twas whispered I might have a 
fall 

From my high estate. 

I grew pompous and proud and vain as could be, 
And continued my song exultingly : — 
" Now and forever, the whole round world wagsj 
To the rhythmic song of the saddle-bags! " 

Oh, 'tis bitter, indeed, that my hopeless disgrace 
Shou'd be caused by a changeable human race 
In its boasted progression (for such they've the 
face 

To proclaim it !) 

Old, battered, helpless, I accept the decree, 
E'en though I muroaur impatiently: — 
" Never again ! the whole round world wags, 
To a later song than the saddle-bags ! " 

There's a lesson of sorrow for you in my song ; 
A lesson for all who believe themselves strong. 
Kemember that pride and great strength belong 
To youth, and lik^ me 
The subject of jeers you may live to be, 
As you childishly moan in your misery — 
" Never again ! the whole round world wags, 
To a later song than the saddle-bags ! " 

— Indiana Med. Journal, 



MEDICAL LEGISLATION IN OHIO. 

Pursuant to call issued by the Cin- 
cinnati College of Medicine and Surgery 
for a delegated convention of the medical 
colleges of the State of Ohio, which was 
held at Columbus, December 3d, repre- 
sentatives of the following faculties were 
present, viz.: Starling Medical College, 
Toledo Medical College, Pulte Medical 
College, Columbus Medical College, 
Medical Department of the National 
Normal University, College of Physicians 
and Surgeons of Columbus, Woman's 
Medical College of Cincinnati and the 
Cincinnati College of Medicine and 
Surgery. 



I20 



Clippings and News Items. 



Vol. Ixvi 



On motion, Dr. Starling Loving was 
elected Chairman and Dr. Charles A. L. 
Reed, Secretary. 

On motion of Dr. C. B. Walton, repre- 
sentatives of the Physio-Medical Society 
of Ohio were admitted to a vote in the 
convention. 

Dr. Charles A. L. Reed presented the 
following : 

Resolved, By the Medical Colleges of 
Ohio, in convention assembled, that the 
Legislature be and is hereby requested to 
enact a law which shall embody the 
following features, viz. : 

1 . The creation of a board or boards of 
medical examiners in the composition of 
which equitable and just representation 
shall be accorded to the various re- 
cognized denominations of medical 
practice. 

2. The examination of all candidates 
for the practice of medicine holding dip- 
lomas hereafter issued by medical colleges 
which shall be deemed in good standing 
by the board. 

3. Exemptions from examinations to 
extend only to those who at the time of 
the enactment of this law shall be 
recognized as legal practitioners within the 
meaning of existing statutes ; but all 
legal practitioners shall be required to 
register. 

4. A penal clause which shall secure 
the enforcement of the foregoing 
provisions. 

Dr. C. E. Walton, on behalf of the 
Legislative Committee of Cincinnati, 
presented the registration law approved 
and promulgated by that committee. 

On motion by Dr. Shockey, the resolu- 
tions presented by Dr. Reed were ap- 
proved. 

On motion by Dr. Kinsman, the secre- 
tary was directed to forward transcripts 
of these proceedings to each local medical 
society in Ohio, and to the medical press. 

On motion by Dr. Scoville, a committee 
was appointed to confer with the Legis- 
lative Committee of Cincinnati for the pur- 
pose of securing such changes in the bill 
proposed by that committee as to make it 
conform to the resolutions adopted by 
this convention. 

The chair appointed as such committee, 
Drs. S. S. Scoville, T. C. Hoover, G. 
W. Mayhew and Chas. A. L. Reed. 

Adjourned. 

Chari^ks a. L. Rkkd, Sec. 
Starling Loving, Chairman. 



MORBID CHANGES IN JOINTS IN 
SYRINGOMYEIvIA. 

The St. Petersburger Medizinische 
WochenscJirift publishes a risume of Dr. 
N. A. Sokoloff's little work on the 
Morbid Changes in Joints observed in 
Syringomyelia. These changes occur, 
according to the author, very frequently. 
They are chiefly observed in the upper 
extremities, and are very chronic. A 
characteristic symptom of these affections, 
as in tabetic arthropathy, is their pain- 
lessness. It is easy to diagnose them 
anatomically and clinically. Fixation oi 
the joints in the early stage of the com- 
plaint, or operative interference in 
advanced and 'marked cases, is indicated. 
— Lancet. ^ 

ARSENIC FOR TRICHINOSIS. 

Dr. W. H. Merrill, Pepperill, Mass., in 
a very interesting article in the New York 
Medical Journal, reports a case of this very 
uncomfortable and usually fatal disease 
in which the administration of liq. potass, 
arsenitis in 5 drops three times a day, and 
increased 3 drops per day until the con- 
stitutional effects of the remedy became 
visible, effected promptly a permanent 
cure in about 25 days from the first dose. 
During the time as much as 36 drops 
were taken during the day, but as soon 
as arsenical symptoms were visible the 
dose was decreased temporarily. Although 
arsenic has not heretofore been noted as 
a remedial in this disease, yet the failure 
of nearly if not quite all other remedies in 
cases where the trichinae were developed, 
and this case being so marked a success, 
warrant its trial in future and the pub- 
licity that can be given to this remedial. 

SULFONAIv IN TRISMUS NASCENTIUM. 

J. Berenyi {Pesiher Medchir. Pressed re- 
ports the case on an infant which on the 
fifth day after birth was attacked with 
trismic convulsions, having five crises in 
as many hours. These crises continued 
with greater or less frequency until the 
eighth day, resisting all treatment. 
Berenyi then administered sulfonal in 3- 
grain doses by rectal injection and by the 
mouth. The crises at once diminished in 
severity and frequency, and ceased com- 
pletely on the sixth day, with no further 
return. The total amount of sulfonal ad- 
ministered was 150 grains, and at no time 
was there noted any tendency to som- 
nolency or other untoward symptom due 
to the remedy. 



Vol. LXVI, No. 4. 
Whole No. 1821. 



JANUARY 23, 1892. 



$5.00 per Annum. 
10 Cents a Copy. 



A Weekly Journal. 



Established in 1853 by S. W. BUTLER, M D. 



THE 



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MEDICAL AND SURGICAL 
REPORTER 

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Entered as Second-Class matter at Philadelphia P. 0. 



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CLINICAL LECTURES. 

Francis Delafield, M. D., Is'ew York. 

Chronic Colitis ; Anaemia 121 

P. D. Keyser, M. D., Philadelphia. 

Pterygium 123 

COMMUNICATIONS. 

Lawrence Turnbull, M. D., P. H. G., Phila. 
The Organs of Hearing and Life Insurance ; 
Cases and Conclusions 126 

T. B. ScHNEiDEMAN, M. D., Philadelphia. 
Ophthalmia Neonatorum as a Cause of 
Blindness 129 

T. RiDGWAY Barker, M. D,, Phila. 

Some Mooted Points Concerning the Vom- 
iting of Pregnancy 133 

John B. Roberts, M. D., Philadelphia. 
Case of Inversion of a Non-Puerperal 
Uterus 135 



ILA.. PA. 



SOCIETY REPORTS. 

Philadelphia County Medical Society . . 137 

SELECTED FORMULA. 
EDITORIALS. 

The Action of Ergot as a Haemostatic in 

Uterine Haemorrhage 141 

The Visiting NurseSociety of Philadelphia 142 
BOOK REVIEWS. 
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Medicine 147 

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Obstetrics 154 

Paediatrics . . 156 

Medical Chemistry 158 

NEWS AND MISCELLANY 159 



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THE 

MEDICAL AND SURGICAL 
REPORTER. 

No. 1821. PHILADEIyPHIA, JANUARY 23, 1892. Vol.. LXVI.— No. 4. 



CLINICAL LECTURE. 



CHRONIC COLITIS— CHRONIC NEPHRI- 
TIS WITHOUT EXUDATION— CARDIAC 
HYPERTROPHY AND DILATATION 
WITH MITRAL STENOSIS 
AND INSUFFIENCY— 
SIMPLE AN^MIA.-^ 



By FRANCIS DELAFIELD, M. D., 

PROFE^SSOR OF PRACTICE OF MFDIClNE, 
COI<IvKGK OF PHYSICIANS AND 
SURGEONS, N. Y, 

CHRONIC COLITIS. 

Gentlemen : This man, 55 years of 
age, gives us the following history : 

Over twenty years ago, in the army, 
he contracted a diarrhoea, which, despite 
treatment, has continued up to the pres- 
ent time. He continues to have from 
two to five small and watery passages a 
day, sometimes containing quantities of 
mucus, sometimes blood. During the 
last few years he has complained of pain 
and distress in the right side and back, 
swelling of the legs and a burning sensa- 
tion in the feet and ankles. He is unable 
to work, and has not eaten solid food for 
the past nine months. He tells us he has 
been taking opium for the relief of his 
diarrhoea, but he had stopped this drug 
eight months ago. I questioned him 
closely, however, and he admits that he 
still takes a half drachm of laudanum 
two or three times a day. The examina- 
tion of the urine, I am told, shows a sp. 
gr. of 1020 and no albumen. 

Putting the man on the table, I ex- 
amined his abdomen carefully by palpa- 
tion and percussion, but fail to find any 
abnormality ; nor would I expect to find 
any, for the history of this case is a 



* Delivered at the Vanderbilt Clinic of the 
College of Physicians and Surgeons. 



straightforward one of chronic colitis. 
Whether there be ulceration or simply a 
chronic catarrh, I am unable to state, but 
it is certain that this catarrh of the lower 
part of the intestines has caused changes 
in the colon so profound by reason of its 
long duration that the colon cannot be 
restored to its normal condition. 

In this patient before us, besides the 
colitis, there has been added the opium 
habit. Though we may believe what he 
tells us that the quantity of opium he is 
now taking is considerably less than 
formerly, yet the habit is undoubtedly 
established. With regard to the treat- 
ment of this case, I must confess that 
very little can be done. The indications 
are to relieve the diarrhoea and improve 
the man's general condition. It is idle 
to look for more. We shall put him upon 
small doses of castor oil — say 20 drops — 
together with tablespoonful doses of cod- 
liver oil twice a day. By this we hope 
to produce better faecal passages, but do 
not expect to improve the condition of 
the bowel. This medication may be kept 
up indefinitely. His diet should be 
largely fluid, milk being the staple 
article. The question arises, should we 
try to make this man give up the use of 
opium ? I do not believe it is worth 
while ; he is old, and moreover, he looks 
like a man who has not long to live. 
The struggle to give up this habit would 
not only cause him great suffering but 
the success of our efforts would be very 
doubtful. I shall urge him, however, 
to decrease the dose he is now taking, or 
at least, promise not to increase it. You 
hear, he volunteers the statement that he 
will give up the opium altogether, but of 
this I am very doubtful. 

CHRONIC NEPHRITIS. 
This woman is fifty years of age ; she 
has the appearance of having been accus- 
tomed to hard work and privation. She 
has come to the Clinic complaining of 



122 



Clinical Lecture, 



Vol. Ixvi 



fainting spells, which she tells us, she 
has been subject to for about eighteen 
years. They are produced by worry and 
excitement and fatigue. At first they 
recurred about once a week, but lately 
they have been more severe and further 
apart. They would come on with a feel- 
ing of faintness and trembling all over 
the body, but without pain or nausea or 
complete loss of consciousness, sometimes 
with palpitation of the heart and some- 
times without. They would last an 
hour or two, or perhaps an entire day. 
During the past year her feet have oc- 
casionally become slightly swollen. Her 
urine has been examined ; the sp. gr. is 
1005, and it contains a trace of albumen. 
The radial pulse, I find, is very feeble at 
both wrists ; it numbers 88 to the minute. 
The heart's action, by auscultation, I dis- 
cover, is also feeble, but there is no mur- 
mur, nor does the heart seem altered in 
size. 

This, therefore, is a case of chronic 
nephritis without exudation, and though 
it must have existed for some time, judg- 
ing by the low sp. gr. of the urine, and 
produced marked changes in the structure 
of the kidney, yet it has caused no 
symptoms except this slight dropsy that 
has appeared lately. It is an example 
of that class of renal disease wherein 
there is nothing much to demand treat- 
ment. 

This woman has worked hard ; has 
probably been often without sufficient 
nourishment and has probably used 
alcoholics. Could we change her con- 
dition of living, we would benefit her, no 
doubt. But this we cannot expect to do. 
As for the attacks of faintness, they are 
almost certainly not due to organic 
disease, but are such attacks as any 
nervous woman is liable to as the result 
of worry and over-work. The feeble 
action of the heart is the only symptom 
that, at the present time, might demand 
treatment. This would suggest the pro- 
priety of trying a cardiac stimulant. It 
is doubtful, however, how much benefit 
would be produced. I should order 
this woman the fluid extract of digi- 
talis, two minims three times a day. 
Let her take this for one week, and if 
she does not improve, I should be inclined 
to give her no medication for the pres- 
ent ; that is, it would not be well to tell 
her she was receiving no treatment, but 
give her a placebo and keep her under 
observation. 



CARDIAC HYPERTROPHY, BTC. 

I now show you a man, 42 years of 
age, who says that, with the exception 
of having had rheumatism off and on for 
the last thirty years, he has been in good 
health up to three or four weeks ago. 
Since this time he has complained of 
some shortness of breath and oppression 
over the heart on stooping or on working 
hard. He has complained also of palpi- 
tation at times, though he has been able 
to work at his trade of street paving up 
to to-day. His urine is said to have a 
sp. gr. of 1023 and to contain no albu- 
men. He has been under treatment at 
the Clinic here, and has been taking iodide 
of potash and nitro-glycerine. As I take 
his pulse I note it is soft (which may be 
due to the drugs he is taking) and also 
that the artery is somewhat tortuous and 
the walls hard and resisting. The ar- 
terial tension is not increased therefore, 
but the vessel is the seat of chronic en- 
darteritis. Inspection of the chest shows 
the apex beat displaced to the left, well 
circumscribed. By auscultation the 
heart's action is found to be irregular 
and intermittent, and not very strong nor 
yet very feeble. I hear distinctly a sys- 
tolic and also a presystolic mitral mur- 
' mur, not transmitted posteriorly. 

This man's condition, then, is a serious 
one. He has endarteritis that has prob- 
ably existed for a long time, and mitral 
stenosis and insufficiency, together with 
considerable hypertrophy and dilatation 
of the left ventricle. How can we ac- 
count for the fact that, with this state of 
things, the patient has been able to con- 
tinue at hard work and free from 
symptoms until within the past month ? 
I think the explanation is to be found in 
this — that his kidneys have remained in 
good condition. This is evidenced by 
the examination of the urine. Should 
this man be sent to bed or confined to the 
house and put upon fluid diet, as you 
have frequently heard me advise in cases 
of irregular and weak heart with arterial 
disease? I do not think it necessary. 
On the contrary, I believe he will be bet- 
ter for a generous diet and moderate 
work and exercise in the open air. In 
the mean while we will tr}- to put the 
heart and pulse in better condition. We 
should bear in mind that in these cases 
the condition of the circulation is differ- 
ent at different times ; the arteries are 
sometimes contracted, at other times not. 
Hence it will be necessary to change the 



January 23, 1892. 



Clinical Lectu7^e. 



123 



remedies according as this or that indica- 
tion arises. Two weeks ago we presume 
there existed a high arterial tension, 
since nitro-ghxerine was given. Now 
this condition is not present. The irreg- 
iilarit}' and the intermittent action of the 
heart are the pronounced symptoms to- 
day, and for these the fluid extract of 
digitalis, m. ij., t. i. d., should be em- 
ployed. And if it be certain that two 
weeks ago there w^as a condition of con- 
tracted arteries, potassium iodide, gr. v., 
should be added to the digitalis. I use 
Squibb' s fluid extract of digitalis now 
altogether in cases of heart disease, in 
preference to the tincture and infusion. 
Its action is more certain and reliable ; 
even a fraction of a minim will often 
produce the desired effect, and two 
minims may be considered a good dose. 
This patient may continue fairly com- 
fortable doing his work, and free from 
dj^spnoea and palpitation for the greater 
part of the time for some years, notwith- 
standing the serious disorder of his heart. 

ANEMIA. 

This young girl, 21 years old, comes 
before us with the following symptoms : 
For the past three 3xars, she says, she 
has suffered from attacks of shortness of 
breath, pain about the heart, nausea and 
vomiting and oedema of the feet. Under 
treatment these sj-mptoms would subside 
but to return again, and in this way they 
have subsided and recurred several times 
during these three years. Her pulse, I 
find, is 120, but not feeble, and the ar- 
ter>^ is not changed nor the tension ab- 
normal. Indeed, such a pulse would 
not direct attention to the heart. The 
examination of the heart is also negative ; 
its action is regular. The urine does not 
contain albumen and its sp. gr. is 1022. 
Investigation shows, therefore, that the 
heart, kidneys and liver are not at fault, 
but attention should be directed to the 
blood. This should be examined ; the 
amount of haemoglobin and the number 
of corpuscles estimated. This would 
probably settle the question of diagnosis. 
There seems to be no doubt from the 
history, however, that the patient is 
suffering from the simple anaemia of 
3'oung women. Such cases are apt to 
improve and then grow worse, and so 
fluctuate between good and bad health 
for a long time. The treatment, of 
course, is iron, but it must be persevered 
in. It is necessar}^, in fact, to administer 



it the greater part of a year or two, or 
until we are satisfied that the disposition 
to relapse has been removed. 

PTERYGIUM. 



By p. D. KEYSER, M. D., 
professor of ophthalmology at the 

MEDICO-CHIRURGTCAL COLLEGE, OF 
PHILADELPHIA. 



Gentlemen . — Pter3^giuni is a growth of 
the bulbar conjunctiva of a triangular 
shape, with its apex pointing towards the 
cornea, and when trangressing on the 
cornea in its progress towards the centre, 
invades onh' that side of the cornea from 
which it comes. It is peculiar in that it 
very rarely, if ever, passes over the centre 
of the cornea ; w^hen it reaches that point 
its advancement seems to stop, but it is 
apt to spread out on the sides, becoming 
wider and thicker. Its shape, position 
and manner of growth are of diagnostic 
value. 

The growth in the conjunctiva may b^ 
thicker or thinner, or broader or narrower, 
according to how it forms in the tissue. 
It is reall}^ a hypertrophic condition of 
the conjunctiva, containing vessels of vari- 
ous calibre and number. At times, strictly 
speaking, it is soleh^ in the conjunctiva, 
which can be readily moved or raised over 
the sclerotica ; at other times, especiallj- 
when thick rigid and tendinous, it maj^ be 
somewhat attached to the underl3dng cap- 
sule of the sclerotica. When on the cornea, 
it is thick, rigid, tendinous and firm, 
like connective tissue in neoplastic for- 
mations. 

It is formed generally on the inner side 
of the ball, at times on the outer, some- 
times on the inner and outer sides to- 
gether, growing towards each other, and 
very rarely on the direct upper or lower 
surfaces. Its growth, however, is in the 
conjunctiva, over the line of the recti 
muscles — very few cases have been re- 
ported lying between the recti muscles. 
It generall}^ starts from the inner canthus 
as a lot of small vessels, with one or two 
longer ones, extending beyond the others 
towards the corneal region. With these 
vessels, a certain amount of thickening 
of the tissue takes place, which spreads 
out fan-like, and slowly enlarges and 
thickens, creeping towards the edge of 
the cornea. When up to the cornea at 
the limbus conjunctivalis, it seems often 



Clinical Lecture. 



Vol. Ixvi 



to be arrested in its long or meridional 
axis, and for years may not encroach on 
the cornea, but all the time becoming 
thicker and broader in the conjunctiva. 
At times it may be inflamed, and at others 
perfectly quiet and cause no trouble or ill 
feeling in the eye. As long as it remains 
in the conjunctiva the vision is not in the 
least affected by it. But after some time, 
which may be years, it begins to develop 
in or across the cornea ; as it does so it 
assumes a tendinous or whitish appear- 
ance, resembling often a thick scar. 
When it begins to creep across the cor- 
nea, it may be noticed that there is a 
line of opacity spreading a considerable 
distance in the corneal tissue ahead of 
the pterygium itself, showing a certain 
amount of inflammator}^ action and fill- 
ing in of the clear nutrient canals of the 
cornea. Two forms of pterygium have 
been distinguished — the true and the 
false — which differ only in a few particu- 
lars as to peculiarities of shape, thickness, 
etc., but are the same in character as to 
generalities and treatment, and therefore 
I describe to you to-day, with these cases, 
the general form and appearance, so that 
you can diagnose such cases and attend 
to them properly. 

It has long been a mooted question as 
to what is the cause of this affection. It 
is a well known fact that it is an inflam- 
matory process, but of a ver}^ subacute or 
chronic form, causing verj^ little, if anj^, 
inconvenience for a long time. Some 
claim it is the result of small ulcers of 
herpetic character, which may occur in 
the conjunctiva and in the cornea, the 
healing and shrinking of these ulcers 
drawing the conjunctiva towards them. 
Others again do not agree in this view. 
The idea has also been given that this 
affection depends on venous thrombosis, 
or narrowing of a corneal and of a vena 
vorticosa, thus de\^eloping disturbances of 
circulation in the corneal portion of the 
ciliary arteries penetrating the recti mus- 
cles. In later years it has been claimed 
to originate from micrococci which be- 
comes deposited in the conjunctiva and 
creeps along over on the cornea with a 
certain amount of inflammatory^ process 
following its track. 

Whatever may be its cause, we well 
know its appearance, and when once de- 
veloped and formed, to a certain degree it 
i ^ permanent, and can only be removed by 
operative interference. It is found mostty 
in advanced life and very seldom in young 



people, while there are certain occupa- 
tions in which persons appear to be prone 
to it.. It is seen very frequently among 
seamen, even in comparatively y^oung 
men. A former student of mine. Dr. 
Chandler, of the Island of Barbadoes, in- 
formed me that a great many^ of the col- 
ored people on that island were affected 
with it. 

Some years ago, I took up the study of 
inflammatory diseases arising from strain, 
from defects in refraction of the eye, and 
in all cases of pterygium, whether in the 
conjunctiva alone, or on the cornea, I 
found some marked degree of compound 
hypermetropic astigmatism. 

A curious feature in connection with 
pterygium, is that it will creep across to 
the centre or apex of the cornea and there 
stop. I may almost say^that it has never 
been known to grow completely^ across the 
cornea from one side to the other ; we 
may, however, have another like growth 
starting from the opposite side, either at 
the same time or later, which will grow 
until its apex almost reaches the centre 
of the cornea, but never quite meeting its 
fellow of the opposite side. 

In looking over the field, we may cor- 
rectly say that we really^ know nothing 
positive as to its cause, except that it 
commences as a small ulcer, with the 
small vessels of the conjunctiva running 
towards it, which gradually^ thickening 
grows toward the cornea, on the edge of 
which it sometimes remains for five, ten, 
fifteen or twenty years, and all at once 
again begins to grow and spread across 
the cornea. When this occurs, there is 
only one remedy^ and that is operation as 
quickly^ as possible. If it grows over to 
the centre of the pupil, no matter what 
method is used in its removal, it leaves a 
cicatricial opaque condition of the cornea, 
leaving it just like ground glass, so that 
the patient is disappointed when he does 
not see perfectly^ after the operation. 
Therefore, always advise the removal of 
this growth as soon as it begins to spread 
over the cornea. It is not wise, however, 
to operate before this time, as it may take 
many y-ears before such a growth will 
commence to invade the cornea, and it 
does no harm until it starts that stage in 
its development. 

One thing I want y^ou to remember is, 
that this condition is not cataract. The 
common idea among the people, and, 
I regret to say, among some phy^sicians, 
is that cataract is something which grows 



January 23, 1892. 



Clinical Lecture. 



125 



over or on the eye. I have had physi- 
cians send cases of pterygium to me under 
the name of cataract. Cataract is an 
opacity of the lens and occurs naturally 
in the eye-ball, while pterygium is an 
external growth. 

Many methods have been proposed for 
the removal of pterygium. The first was 
to grasp the growth with a pair of forceps 
and cut it off with the scissors, leaving a 
triangular opening in the bulbar conjunc- 
tiva to fill with granulations. Where the 
growth was large on the cornea, it was 
shaved off with a knife and then the scis- 
sors used to remove the conjunctival part. 
But in this operation, it was often found 
that a return of the growth occurred, 
which was more difficult to remove on 
account of a firm attachment to the sclero- 
tica. To remove this secondary danger, 
an improvement was made in not cutting 
the triangular piece out of the conjunc- 
tiva, but cutting back along the margin 
on either side of the growth, and allowing 
it to fall down and recede by gradual 
absorption, while the conjunctiva is 
brought together over the wound, cover- 
ing up the space from which the growth 
has been removed. Then again, instead 
of letting the excised part fall down for a 
long, slow absorption, a good improve- 
ment was throwing a ligature around it 
and so causing it to slough off in a few 
daj^s, while the triangular space, being 
covered by drawing the conjunctiva over 
it, heals up. Ligation has been tried. 
Szokalski suggested a very ingenious 
method of passing ligatures around the 
growth and causing it to slough off. This 
method, however, is seldom used. 

Transplantation has been made w4th 
success, especially in very large and 
broad growths. This is done to relieve 
or prevent the retraction of the conjunc- 
tiva, which is liable to take place where a 
great amount of that tissue is removed and 
interferes very much in the mobility of 
the eye-ball. In this operation, the 
growth is turned up into an incision in 
the conjunctiva on the upper part of the 
ball. But if the pterj^gium is ver}^ broad 
it is much better to split it down the 
middle after its separation from the cornea 
and conjunctiva, and transplant one half 
upward and the other half downward. 

A very easy and simple, as well as suc- 
cessful, method, has been lately intro- 
duced for the removal of this growth 
from the cornea when its attachment is 
not too deep in the corneal tissue. Gene- 



rally, the attachment of the pterygium 
in its growth over the cornea, is super- 
ficial and only to the anterior layer, from 
which it can readily be torn, so, by forceps 
or a strabismus hook under it, it can be 
pulled away from the cornea. The 
apex recedes and the conjunctiva is 
brought together on the line contiguous 
to the cornea. 

Now, gentlemen, I have two well- 
defined and very different cases of this 
disease to present to you to-day. The one I 
first show you has been growing for years ; 
you see the patient is an old man. The 
growth extends almost to the centre of 
the pupil and spreads out in the conjunc- 
tiva, fan-shaped, towards the inner can- 
thus, so broad as to cover almost that 
side of the ball. It is too large to dissect 
up and remove, so I shall divide it and 
transplant one half above and the other 
half below. I first take up the thick 
tissue in my forceps, and with the scissors 
make a small opening along the upper 
border of the same, near the cornea, and 
one on the lower edge immediately below 
it. Through this I pass a strabismus 
hook so as to lift it up, drawing from the 
cornea, at the same time grasping the 
corneal part with my fixation forceps to 
aid in pulling the growth off the cornea. 
Now, having done so, I cut on either 
side back to the ball, and dissect it up 
loose, and then make with my scissors a 
curved incision in the conjunctiva above 
the cornea on the top of the ball and an 
incision in the lower part. I now split 
the pterygium straight down its centre to 
the base and then turn each half into its 
new position in the conjunctiva and 
fasten by sutures. The second case I 
show you is of much smaller growth, 
and not spread out much in the conjunc- 
tiva. In this case I shall only draw or 
tear the corneal attachment loose in the 
same way as I did the former operation, in 
and let the apex of the pterygium recede 
back from the cornea, and then draw the 
conjunctival wound together to cover the 
gap made. The thickened part, or apex, 
gradually shrinks away, so that in a 
short time very little, if anything, 
remains to be seen. 

This tearing the growth from its cor- 
neal attachment appears to have many 
advantages, and is a great improvement 
on its removal by cutting. When cut or 
shaved off, considerable opacity remains, 
and often a thickened, firm, tissue-like 
prominence. 



Communications. 



Vol. Ixvi 



The attachment seems to be rather 
superficial, not passing into the deeper 
tissues of the cornea, but fastened b}' 
little filaments which take only slight 
hold upon the anterior laj^er , so that simply 
by pulling it gently, the attachments are 
broken loose, and a more or less clear 
cornea remains. 



COMMUNICATIONS. 



THE ORGANS OF HEARING AND LIFE 
INSURANCE. 

(Translated from the works of Dr. Josef Gruber) 
By LAWRENCE TURNBULL, M.D., P.H.G., 

PHII^ADEIvPHIA, 

and 

S. W. STEINBACH. M.D., 

PHII.ADKI.PHI A. 

The examination of a candidate for ad- 
mission in a life insurance company by 
the aural physician should solve the 
three following questions : 

First, — Is the life of the individual in 
question endangered by the condition of 
his organs of hearing ; if so, to what 
degree ? 

Second. — Has the ear affection any 
connection with other local or general 
affection ; if so, what is the connection ? 

Third. — What is the relation of the 
special disturbed function of the ear, 
more especiall}^ with reference to the 
following of the vocation, or would it 
invalidate the policies or militate against 
the individual to be insured ? 

Everyone who is even partially initiated 
will be able to perceive by these ques- 
tions alone what knowledge is required 
for their proper solution, and how, in 
doubtful cases, a recourse must be had 
to the judgment of the more experienced. 
Even the judging of the average case 
will be made more easy to the less ex- 
perienced physician if the points for the 
formation of a diagnosis are indicated to 
liim. 

The statements of the patient, as 
elicited by oral examination, will be of 
the greatest interest, but we must be 
guarded, so as not to be too credulous, 
and try always to ascertain, by an ob- 
jective examination, whether the pa- 
tient's statements can be made to har- 
monize with the existing condition of the 
organs of hearing. 



It is not intended here to say that the 
statements of the individual must, in 
every case, be confirmed bj^ a positive or 
negative result of an examination, for the 
objective examination generalh' gives a 
negative result in those cases where the 
functional disturbances ma}^ be the most 
detrimental to the individual's capabilit\^ ; 
e. g., in those produced b}^ a primary or 
secondary labyrinthine lesion, where the 
objective examination gives frequently a 
completely negative result. It is the 
case of those individuals who desire to 
be admitted into a life insurance com- 
panj^ that they attempt to conceal their 
aural affections, which occasionally are 
very dangerous, or the}- \ry to at least 
underrate the significance of their ear 
diseases and then the objective result (of 
the objective examination) must cor- 
respond with the respective statements. 
We are in favor of allowing the indivi- 
dual about to be examined to relate his 
own history of the affection, and then 
complete and purifj^ his statements by 
appropriate questions. Very often the 
physician's attention will thus be led to 
points which he otherwise would have 
overlooked. 

The objective examination of the or- 
gans of hearing ma}^ be divided into an 
ocular, tactile and auscultatory, and 
should be conducted with the greatest 
exactness, more especially as regards the 
relation which it bears to the organism 
at large. In my hand-book, published 
by C. Gerold's Son, in Vienna, the 
various methods of examination are care- 
fully detailed. The limited space here 
does not admit of a more thorough con- 
sideration of the subject, and I, there- 
fore, must refer to that work, and proceed 
to at once, commencing in anatomical 
order from without inwards, mentioning 
and elucidating those sypiptoms which are 
of the greatest importance to the diagno- 
sis in the prognosis of diseases of the ear. 

A. External Auditory Portion. — First 
we consider the neighborhood of the 
pinna. Inflammator}^ swellings of the soft 
part, irritative swellings of the h^mphat- 
ics, especiall}^ those in the maxillamas- 
toid fossa, and at the mastoid process, 
fistulous pus- tracts in this region, as well 
as swelling of the mastoid process, es- 
pecially when all these appearances last 
long, they are frequenth' to be regarded 
as the consequences of serious affections 
of deeper structures, dangerous to the 
life of the individual. 



January 23, 1892. 



Communications, 



127 



Great attention must be paid to ulcer- 
ated surfaces in this region and those on 
the pinna, for they are occasionally the 
expression of a carcinomatous degenera- 
tion, only to be diagnosed by the use of 
the microscope. Fistulous tracts should 
be explored carefully, which may lead to 
a detection of the condition of the bone 
and of the original seat of the affection. 
Occasionally in the swelling of the lym- 
phatics in the mastoid region is connected 
with affections of the ear, which is only 
a part appearance of a general lesion, 
namely syphilis and scrofulosis. I must 
here emphasize that I have often seen 
cases where the appearances in and about 
this region were the first signs of a con- 
stitutional syphilitic affection that had 
made itself manifest. Ulcers of the pinna 
itself are occasionally the result of con- 
stitutional syphilis, or they may be of a 
lupus or carcinomatous nature. In a far 
progressed gouty affection, deposits are 
not infrequently found in the pinna. 
Haematomes occur here as neoplasts of a 
local importance, only the so-called 
othaematom might in one case or another 
be connected with other affections of the 
vascular system. Foreign masses in the 
external auditory canal, including the 
accretions of cerumen, must first be re- 
moved in an appropriate manner, so as to 
gain an accurate insight into the deeper 
sections. Here it may be mentioned that 
occasionally cholesteatomes proceed from 
the deeper sections of the same into the 
auditory canal, where the newly formed 
mass easily mixes with cerumen, assumes 
its color, and may give rise to great er- 
rors. 

Inflammatory affections of the external 
auditory canal are to be judged with 
reference to the functional data and gen- 
eral appearances. When such exudative 
processes are connected with great swell- 
ing of long standing of the soft struc- 
tures, and especially when connected 
with increase in size of the bony por- 
tions, when polypi appear in the auditory 
canal, when probably pieces of bone 
have escaped, they always awaken a 
suspicion of caries or necrosis. I wish 
particularly to emphasize that only very 
rarely can a diagnosis with the ordinary 
surgical methods of examination be ob- 
tained in an affection of bone located in 
the deeper seated portions of the tem- 
poral bone, because the probe, in most 
cases, does not reach the affected portion 
at all. The diagnosis must be made with 



the aid of the microscope, periodically 
examining the masses removed from the 
auditory canal. 

In bone implication, small particles 
will be found which will furnish the 
surest proof of the presence of caries or 
necrosis, especially if the examination 
has been conducted with appropriate care. 
When polypoid growths are present in 
the auditory canal, a microscopical exam- 
ination will furnish a solution of their 
specific character ; some, although rare, 
appear as carcinomatous neoplasms. 

The appearances on the membrana 
tympani call for the most thorough con- 
sideration, because from it we can diag- 
nose not only those affections that have 
their seat in the membrane itself, but 
frequently we can, from it, judge the con- 
dition of neighboring organs, especially 
the bearing of the scructures of the 
middle ear. Opacities of the membrane 
are most frequently connected with dis- 
eases of the structure of the middle ear, 
especially when they present an arched 
(semi-circular or circular) appearance ; 
these affections may, in a great degree, 
endanger the power of hearing. Poly- 
poid growths on the membrane and per- 
forations with contemporaneous continu- 
ous or periodical otorrhoea go frequently 
hand in hand with dangerous inflamma- 
tory diseases, and merit the greatest at- 
tention. Perforations of the membrana 
tympani become free from danger to the 
deeper structures generally only when 
the otorrhoea has long ceased and the 
mucous membrane has become sclerosed. 

B. Middle portion. — In this portion of 
the ear we find mostly those diseases 
localized which, on one hand, may be- 
come dangerous to the life of the indi- 
vidual, and, on the other, cause difficulties 
in hearing, or other unpleasant conse- 
quences. To expose the condition of this 
portion of the organ of hearing, the 
physician must direct his attention to all 
those parts which stand in any relation 
with it : the auditory canal and the 
membrana tympani, and also the struc- 
tures in the neighborhood of the mastoid 
process, the nasal and pharyngeal 
regions ; for not infrequently important 
and substantial affections of the middle 
ear spread their noxious influences hither, 
or are occasionally even the . result of 
primary affections of these structures. 
In judging of the results obtained by the 
various methods of examination, the 
general condition must be considered, 



128 



Commmiications. 



Vol. Ixvi 



and we must not precipitatedly make a 
diagnosis, because the most experienced 
is often enabled to make a proper diag- 
nosis only after repeated and protracted 
examinations. This is more particularly 
the case with reference to the so-called 
dangerous caries or necroses, which are 
often seated so hidden that they do not 
betra}^ themselves to the most experienced 
eye. The microscopical examination of 
the discharge from the ear, or a fistule, 
as mentioned before, will soonest and best 
furnish an explanation. Since the long- 
existing and profuse otorrhoea is no sure 
sign of caries, so we, on the contrar}^, 
must not conclude the opposite to be the 
case from a temporary or complete cessation 
of the same, and the physician must 
build up his diagnosis and form a prog- 
nosis from all the appearances within and 
without the organ of hearing. 

I^et it be mentioned here once more 
that the nasal and phar3mgeal examina- 
tions must be conducted with the greatest 
minuteness, for occasionally there occurs 
in the middle ear only the simplest signs 
of an inflammatory process, while in the 
nose and pharynx syphilitic and carcino- 
matous degenerations are carrying on 
their destruction. 

C. Internal Ear. — Life is seldom, if 
ever, endangered by primary affections 
of the labyrinth. The connections of the 
internal ear serve frequently as conduc- 
tors of dangerous diseases from the middle 
ear to the brain or its membranes, and 
thereby cause a fatal termination. , On 
the other hand, it is evident that diseases 
of the brain of a dangerous character 
extend to the auditory nerves and the 
labyrinth, and from this point betra}^ 
their existence, and, like general lesions, 
assert their noxious influence upon the 
organ of hearing. 

Concerning the capability of the indi- 
vidual to self-support, or of the expected 
or already existing invalidity of an indi- 
vidual, we will have to consider, not 
alone the existing forms of ear disease, 
the degrees of disturbances of hearing, 
and other subjective symptoms, but also 
the occupation of the patient. 

A rationally managed insurance com- 
pany will allow this rule to stand at the 
acceptance as well as in the act of declar- 
ing a policy invalid. 



CASES AND CONCLUSIONS. 



By LAWRENCE TURNBULL, M. D. 



The great importance of a critical ex- 
amination of the organ of hearing before 
a polic}^ of insurance is issued to an 
individual suffering from ear disease, is 
well shown in the preliminary article b}' 
Professor Gruber, of Vienna, translated 
by my friend and pupil, L. W. Steinbach, 
M. D. Cases are frequenth' presented for 
our examination in which, to all appear- 
ance, the individual is in perfect health, 
yet there is a slight discharge from one 
or both ears. We cite a case in point. 
A gentleman, W. H., aged fort3^-two, 
presented himself for our examination, 
and he made very light of a discharge 
from the ear, which he stated had existed 
for 5'ears and only required cleansing 
once a day, and gave him no trouble. 
We told him of the great risk he ran of a 
sudden cold being taken during im- 
prudent exposure which might cause his 
death. He was not considered a good 
risk. There was a perforation of the 
drum membrane and discharge. His 
family historj^ was good. His father had 
lived to a good old age. This discharge, 
in connection with the grippe, was 
ultimatel}^ the cause of this 3^oung man 
being cut off before he reached the age of 
45 years, the normal period of longevity. 
This suppuration from his ear of so long 
a continuance had destroj^ed the lining 
membrane which covers the delicate bone 
of the part and this was followed by 
ulceration and necrosis of the bone 
forming the roof of the middle ear 
(t)'mpanum), and the next scene was 
abscess of the brain and death. Another 
form of ear disease which would prevent 
the issuing of a polic}^ as a first-class risk, 
is in cases where there is disease of the 
bone, the temporal especiall}- being in- 
vaded, propagation along the Fallopian 
canal ; involvement of the facial portion of 
the seventh pair of nerves, causing what 
is termed facial paralysis. We have met 
with several cases of this form of disease 
of the ear, and three of them recently. 
The first arose from an acute attack of 
chronic catarrh of the t^^mpanic cavit}^ 
which had existed for j^ears with the en- 
tire loss of hearing for one ear, and 
caused another chronic tympanal dis- 
ease, with very imperfect hearing, in the 
other. Fortunately local depletion and 
aconite relieved the prominent sj^mptoms 



January 23, 1892. 



Communications. 



of fever, etc., in the first instance, and in 
the other with very large doses of iodide 
of potassium, even up to 100 grains a day, 
recovery occurred entirely in a month's 
time. The second was the result of a 
chronic discharge from the ear with loss 
of the drum membrane followed by ex- 
tensive disease of the bone, which had 
been treated three years before with suc- 
cess by scraping, and the patient had been 
free from discharge and pain for three 
years. The disease again showed itself 
by a bloody discharge with severe facial 
paralysis, loss of power over the face, and 
falling of the eyelid, so that the latter 
had to be supported for months with a 
strip of isinglass plaster. A prolonged 
treatment by cleansing, antiseptic 
washes and the internal adminstration of 
the iodide of potassium, and then the 
^ 'four chlorides' ' have almost restored the 
function of the nerve and the power of 
the eyelid and face, but it is liable to 
relapse. The third case was a patient in 
Jefferson College Hospital. The condi- 
tion of the ear and face was the direct result 
of the poison of secondary sj^philis, and 
was cured by a long continued course of 
mercury. 

Another large class of cases which 
cannot be accepted as first-class risks, are 
those where we have diseases of the 
mastoid cells (just back of the ear) and 
forming the air cells of the middle ear. 
Numerous cases of sudden death follow 
the neglect by the surgeon to remove the 
diseased bone. 

The last class of cases are those 
apparently of slight ear disease in which 
we have a thin watery discharge during 
the early state of tuberculosis, but which 
is followed and kept up by the increase 
■of the cough, and in which no local or 
general medication is of any avail. 
Persons with a persistent cough, dullness 
at the apex of the lung, and a discharge 
from the ear we consider far from being a 
_good risk for life insurance. Simply 
defective hearing, so that the individual 
cannot hear the human voice loudly 
spoken within a few feet, is apt to lead to 
accidental death in crowded streets or at 
a railroad crossing. Some insurance 
companies, both in this country, in Eng- 
land and on the continent of Europe, 
refuse under any conditions to accept 
any one suffering from an otorrhoea. We 
fully agree with our revered friend, the 
late Dr. Cassells, in that this rule of pro- 
cedure is too sweeping, for there are 



many cases of ear disease with tissue 
lesion only in which there are reasonable 
grounds for saying that, inasmuch as the 
ear discharge is simpl}^ an excessive 
secretion from hypertrophied tissue, or 
at all events not the results of an ulcera- 
tive process either of these or the under- 
lying bone, there may be a healthy consti- 
tution with no tuberculous, syphilitic, 
scrofulous or other history. 

Under proper treatment many cases 
can be permanently cured and all dis- 
charge arrested ; therefore, such cases 
should be accepted. In severe cases 
there might be an additional increase of 
premium. All suspected and question- 
able cases should in every instance be 
submitted to the critical examination of 
an expert in otology. 
1502 Walnut St. 

OPHTHALMIA NEONATORUM AS A 
CAUSE OF BLINDNESS.* 



ByT. B. schneideman, M. D., 

PHII.ADEI.PH FA. 



My object in bringing this subject before 
the Society is to direct attention to a 
disease which is responsible for about 
one- third of all cases of blindness, of 
which a most important means of preven- 
tion — that of public legislation — can only 
be obtained by the active intervention of 
medical societies. The following case is 
presented, not because of its novelty, un- 
fortunately, but as somewhat typically 
representing the lamentable result of 
negligence or ignorance : 

H. M., age three. Both eyes became 
sore when five days old. O. D. : Dense 
adherent leucoma lower inner portion of 
cornea. Remainder of cornea hazy, 
stretched blue- gray iris in contact with it. 
Globe apparently somewhat distended ; 
leucoma prominent but easily covered by 
lids, T. : Normal. O. S. : Leucoma 
slightly denser and more prominent but 
not larger. Broader space of translucent 
cornea than O. D. R. and L. light per- 
ception. 

The subject has been very thoroughly 
worked out in Europe, and a mass of 
statistics has been accumulated. Accord- 
ing to the report of the Royal Commis- 
sion on the Blind, published in 1889, 30 



* Read before the Philadelphia County Medical 
Society, December 9, 189 L 



I30 



Communications. 



Vol. Ixvt 



per cent, of the inmates of the institu- 
tions, and 7000 persons in the United 
Kingdom, have lost their sight from this 
cause. Professor Magnus, of Breslau, 
finds that no less than 72 per cent, of all 
who become blind during the first year 
of life are rendered so by purulent oph- 
thalmia ; and even of those who become 
blind before the twentieth year of life, it 
constitutes as much as 23.50 per cent. 
Looking at the subject in another way, 
he shows that of 10,000 children under 
five years of age, 4.28 are blinded by 
purulent ophthalmia. In the blind 
asylums of Switzerland the proportion 
who have lost their sight from this 
disease is 26 per cent. ; in the asylums of 
Austria, Hungary, and Italy, about 20 
per cent. ; while in Spain and Belgium 
it falls to about 11 or 12 per cent. And 
in this city, Dr. Harlan, as the result of 
examination of the eyes of 167 inmates of 
the Pennsylvania Institution for the 
Blind, found that 55 owed their affliction 
to purulent ophthalmia, and more than 
half of these were of the form occurring 
in infants. 

The lesson taught by such statistics is 
not simply that ophthalmia of the new- 
born is the most common cause of blind- 
ness ; if that were all, they would, no 
doubt, still preserve a melancholy interest, 
but they have a much greater importance, 
for they tell us that it is quite within our 
power to have prevented the great afflic- 
tion of blindness in one-third of those 
who are deprived of sight. For it is 
hardly too much to say that no one should 
lose his sight from this disease, not only 
because it is quite amenable to treatment, 
if this be instituted from the beginning, 
but because the disease itself can be pre- 
vented in most instances if those who 
have the care of mother and child under- 
stand the nature of this affection. 

Ophthalmia of the newborn is an 
infectious disease, and can only occur 
after the infectious matter has come into 
actual and somewhat prolonged contact 
with the conjunctiva. The noxious 
matter is in every instance derived from 
an inflamed vagina (or urethra), or from 
another eye. In the great majority of 
cases infection takes place from the 
vagina, and it is to be remembered that 
the disease is not caused by the secretion 
of a specific (gonorrhoeal) catarrh only, 
but that it may be produced by the secre- 
tion of a simple leucorrhoea, or at least 
by what is recognized as such clinically. 



As regards the period when infection 
occurs, this ma}^ take place either during 
or immediately after birth, or at some 
subsequent moment. In the former case, 
the materies morbi is derived directly 
from the vaginal secretion. The child 
passes through the parturient canal with 
closed eyes, hence during the passage of 
the head the secretion can only penetrate 
into the conjunctival sac in very small 
amounts, if at all, but it remains adher- 
ent to the eyelashes and edges of the lids^ 
and can readily gain an entrance into the 
eyes as soon as these are opened and the 
child winks upon the escape of the head. 
Infection may take place during birth, if 
anything occurs to displace the soft parts 
of the face, as may happen in protracted 
and difficult labors, large size of head, 
etc. , conditions more likely to be present 
in primiparse, and with the larger heads 
of male children. But the time most 
fraught with danger is usually the 
moment the head escapes and the child 
first opens its eyes. In the majority of 
cases, infection takes place at some time 
during labor, and the disease first 
manifests itself from the second to the 
fifth day ; if it does not appear until 
later, infection took place subsequent 
to birth. This may happen by the 
transference of secretion to the child's 
eyes in various ways, as by the hands 
of the attendant, by soiled linen or 
sponges, etc.; but the lochial discharge, 
as such, has been found to be incapable 
of causing the affection, if the woman be 
free from disease. 

The discovery of the gonococcus has 
led investigators to examine the secretion 
of purulent ophthalmia for the same 
organism — and in the vast majority of 
cases examined it has been found to be 
present therein also ; still, different 
observers appear to have reached results 
not entirely in accordance as to the re- 
lative frequency with which this organism 
is present. Cases do occur in which it 
cannot be found. Hence the attempt has 
been made from a bacteriological point of 
view to recognize different forms of the 
disease — a specific form and simple in- 
flammatory forms. As stated above, 
the secretion of simple vaginal catarrhs 
are capable of causing purulent oph- 
thalmia. 

Formerly this disease was attributed to 
a variety of causes, such as injuries re- 
ceived by the eyes during birth, icterus, 
chilling of the body, intense light, etc.. 



January 23, 1892. 



C ommunica Hons. 



but these views are, of course, no longer 
entertained. Ordinary pus and even de- 
composed pus cannot produce it. Puru- 
lent secretions from lachrymal abscess 
and caries of the orbit frequently get 
into the eye, and do produce inflamma- 
tion of the conjunctiva, but not the oph- 
thalmia of the newborn with its great 
liability to involvement of the cornea. 
Putrid flesh, putrid blood, and even pure 
cultivations of various microorganisms, 
have been introduced into the conjunc- 
tival sac without any ill effect. 

Prophylaxis, to be efiicient, must, of 
course, first of all recognize the infectious 
nature of this affection, and secondly, 
the source whence the infectious matter 
may be derived. 

Among general measures are to be 
placed all influences which can be em- 
ployed to impress upon the public the 
dangerous character of all affections of 
the eyes of young children. Like all 
similar diseases, this affection is most 
prevalent and destructive among the 
poorer classes, who do not usually em- 
ploy a physician to attend them in con- 
finement, but rely upon a midwife too 
often but little better instructed than the 
woman she attends. 

In some dispensaries for the treatment 
of diseases of children, a small tract is 
handed the mother or attendant who 
brings the child, giving advice as to the 
proper care of infants, their diet, bath- 
ing, etc. A few lines might be added, 
calling attention to the serious nature of 
this inflammation — ignorance of which 
and the proneness to ascribe every affec- 
tion to "catching cold," which will get 
well of itself, is responsible for many 
ruined eyes. With this end in view, it 
might be advisable to have articles appear 
in the public prints from time to time ex- 
plaining the danger of the disease in 
question, and urging the importance of 
immediately attending to every case of 
inflammation of the eyes of the young 
child. Kven the ignorant classes under- 
stand the dangerous nature of certain 
other diseases, such, for example, as 
diphtheria and scarlet fever, and if oph- 
thalmia of the newborn could be added 
to these, the deplorable results of neg- 
lected cases would be less frequently 
observed. 

To reach this class (which is undoubt- 
edly responsible for the great majority of 
those unfortunates who have become blind 
from this disease, namely, midwives), it 



has been proposed to compel all such ta 
report every case of ocular inflammation 
at the earliest possible moment to some 
physician. Such laws are in force in 
certain countries of Europe, and there 
appears no good reason why a similar law 
might not be enforced in this country, 
just as there are laws requiring other con- 
tagious diseases to be reported. If this 
could be done with any degree of efficien- 
cy, it would do more toward abolishing 
loss of sight from this cause than any 
other measure. The State of New York 
has such an act in operation, requiring 
midwives and nurses to report every case 
of inflamed or reddened eyes occurring 
within two weeks after birth to some 
legally qualified practitioner within six 
hours, under penalty of a fine or imprison- 
ment, or bpth. This law has been in 
operation for a little more than a 3^ear, 
and it is hence too early to obtain much 
information as to its practical working. 
A few convictions would direct the atten- 
tion of that class which it is desired to 
reach to this subject, and in this way, at 
least, be productive of a certain amount 
of good. 

As regards special measures of prophy- 
laxis, these were clearly formulated as 
early as 1807 by Gibson, in the following 
ing principles, which all later experience 
has tended to confirm. They are, first, 
to cure the leucorrhoea of every pregnant 
woman when possible,; or failing in this, 
second, to disinfect the vagina during 
labor ; and third, to remove the secretion 
from the child's eyes immediately after 
birth by a fluid which renders the secre- 
tion harmless. 

Notwithstanding their importance, I 
shall here pass over the first two and con- 
sider briefly the third of these indications. 
Of all the methods employed, none have 
yielded better results than the one recom- 
mended by Crede. This consists in drop- 
ping into the eye a two per cent, solution 
of nitrate of silver after simple prelimin- 
ary washing with clean water. Other 
agents, such as carbolic acid and boracic 
acid, have been tried, but none gave re- 
sults so satisfactory as the silver, perhaps 
because the latter has the power of pene- 
trating deeper into the tissues. As a 
proof of the efficacy of this procedure in 
diminishing the number of cases of puru- 
lent ophthalmia of the new-born, the fol- 
lowing figures, all obtained from the same 
hospital and the same attendants, furnish 
the evidence : 



132 



Communications. 



Vol. Ixvi 



Chil- Treatment. Per ct. of Per ct. of Total, 

dren. blenorr. catarrh. 

1092 No treatment . . 4.75 14.5 19.25 

1541 2 per ct. of carbolic acid 1.42 .6 7.42 

1250 2 per ct.ofsilver nitrate 0.72 4.72 5.44 

And similar good results have been ob- 
tained in other lying-in hospitals. Still, 
this method, which is somewhat severe, 
is not necessary in every case in private 
practice, although, even if unnecessary, it 
is quite devoid of serious danger. As a 
milder measure, simple washing the eyes 
with clean water as soon as the child is 
born has been found efficient in diminish- 
ing the number of cases of the disease 
— while in any case in which there is a 
history of copious purulent discharge 
from the vagina, it would be advisable 
to employ the silver solution as recom- 
mended by Crede. 

As regards the disease itself, it is almost 
superfluous to present any formal descrip- 
tion ; its phenomena are so characteristic 
that it is impossible to mistake its nature 
when fully developed. The swollen and 
reddened eyelids, the upper drooping and 
partially overlying the lower, the great 
difficulty or even impossibility of opening 
the eyes, the profuse purulent discharge 
welling forth as the lids are gently sepa- 
rated by the finger, the pain and heat, the 
swollen conjunctiva, rising like a mound, 
in which the cornea is buried, all these 
go to make up a picture which can- 
not be overlooked nor confounded 
with any other. But that every in- 
flammation, however slight, affecting 
the eyes of a new-born child may, if neg- 
lected, become the fully developed disease, 
and that, too, in a day or two, should al- 
ways be in the mind of every one who has 
any connection with the case. 

The danger of this disease consists, of 
course, in the great liability of implica- 
tion of the cornea, leading to perforation 
of this structure, with the serious results 
dependent thereon. It was formerly be- 
lieved that the cornea, being an avascular 
structure, became affected from interfer- 
ence with its nutrition by the pressure of 
the swollen conjunctiva, but while such 
pressure may be unfavorable to the nutri- 
tion of this structure and predispose it to 
yield more readily, the direct cause of 
the corneal disease is infection from the 
microorganisms which have their nidus 
in the profuse purulent secretion, upon 
the recognition of which depends the ra- 
tional and efficient treatment of this dis- 
ease. This consists, first of all, in the 



removal of the pus from the conjunctival 
sac as soon after it is secreted as possible ; 
and second, to render innocuous any por- 
tion of the secretion which remains in the 
eyes by appropriate germicides ; and 
thirdly, to act upon the inflamed secreting 
membrane by some agent capable of 
modifying this surface and checking or 
diminishing its secretory activity for the 
time being. 

The particular means adapted to carry 
out these indications are various, and the 
methods selected vary somewhat, accord- 
ing to the preferences of different physi- 
cians. To disinfect the conjunctival sac 
almost all the antiseptics employed in 
general surgery have been used, and with 
more or less good effect. The following 
plan has been found so efficient as to 
leave little to be desired : The attendant 
should remove the pus once every hour 
during the height of the disease ; this can 
be done by gently separating the lids and 
flooding the conjunctival sac repeatedly 
with an ordinary pipette or dropper until 
the cleansing fluid returns clear and un- 
mixed with pus. The fluid employed is 
a rather strong solution of bichloride of 
mercury, i : 2000. Besides its mechani- 
cal effect in flushing the sac and so re- 
moving the pus, it is one of the best 
germicides that can be employed and 
withal entirely safe. Other agents might 
be made use of, such as carbolic acid in 
two percent, solution, saturated solutions 
of boracic acid, though the latter seems 
inert as a germ destroyer, at least accord- 
ing to laboratory experiments, nitrate of 
silver, etc. , but none of these agents have 
any advantage over the bichloride. To 
meet the third indication, to modify the 
inflamed membrane, a rather strong solu- 
tion of nitrate of silver, ten, twenty, or 
even forty grains to the ounce, should be 
applied once, or perhaps twice, in the 
twenty- four hours to the everted lids by 
the surgeon. The application can be 
readily made by wrapping a pledget of 
absorbent cotton around a match stick, 
dipping into the silver solution until 
saturated and then gently and thoroughly 
applying it to the palpebral conjunctiva. 
No subsequent washing with sodium 
chloride solution is necessary. The 
above treatment, simple as it is, gives 
results entirely satisfactory. I do not 
recall a single case in which it was prac- 
ticed that did not result in perfect re- 
covery without damage to the cornea, 
although in some cases the disease had 



January 23, 1892. 



Communications. 



133 



existed for a number of days and in a 
number of instances the cornea was so 
greatly infiltrated when the patient first 
came under treatment as to cause fears of 
immediate perforation. In those cases 
in which the cornea becomes affected, as 
evidenced by partial opacity, atropine, 
or, in some cases, eserine, should be in- 
stilled into the eye — for if, unhappily, 
perforation should occur, the eye will be 
more likely to preserve some degree of 
useful vision if prolapse of the iris can be 
avoided. 

If one eye only is affected, the question 
arises how to prevent infection of the 
other eye. The shield, to protect the 
sound eye, is not applicable in infants as 
it is in adults. Great cleanliness, con- 
stant removal of the secretion, making 
the child lie on the affected side, will 
prevent infection in many cases. It 
might also be advisable to use the bi- 
chloride or the silver solution as a pro- 
phylactic measure. 

Finally, in those cases in which per- 
foration, with its usual results of adherent 
iris, etc., has occurred, something may 
be done by operative interference if any 
portion of the cornea remains clear. 
Here the indications are to free the iris 
from its adhesions to the cornea lest total 
staphyloma supervene. This procedure 
may be difficult to carry out, may involve 
extraction of the lens, and in any case 
would hardly give more than perception 
of very large objects. — ^ For discussion, see 
Society Reports. ) 



SOME MOOTED POINTS CONCERNING 
THE VOMITING OF PREGNANCY.* 



By T. RIDGWAY BARKER, M. D., 

DEMONSTRATOR OF OBSTETRICS IN THE MEDICO- 
CHIRURGICAI, COI.I.EGE, PHILA. ; OUT-DOOR 
OBSTETRICIAN TO THE PENN DISPENSARY. 

In discussing the etiology, symptoma- 
tology, and prognosis of the digestive 
disturbance associated with gestation 
known as morning sickness, or the vomit- 
ing of pregnancy, it becomes necessary 
at the very outset of a comprehensive 
study of the subject to exclude those 
forms of gastric trouble which, while often 
accompanying this purely physiological 
process, are nevertheless not dependent 
upon it for their existence, but upon 



*Read before the Philad'a Co. Med. Soc, Decem- 
ber 23, 1891. 



some preexisting morbid condition which 
is simply aggravated by the changes 
incident to gestation. 

From a failure to appreciate and differ- 
entiate between these forms of gastric 
disturbance is largely due the confusion 
and misconception which is so general, 
hence the existence of such a multitude 
of views as to the cause and gravity of 
the vomiting of pregnancy. 

It becomes necessary, therefore, that 
we state clearly that when we speak of 
morning sickness we do not include the 
so-called vomiting in pregnancy, but 
confine our remarks solely to the vomit- 
ing of pregnancy. Without further ex- 
planatory remarks, let us proceed to a con- 
sideration of the subject from a scientific 
standpoint, ever mindful, however, how 
easy it is to advance a theory and how 
difficult to find evidence to support it. 
That the occurrence of vomiting without 
apparent cause in females who have ex- 
posed themselves to the risk of conception 
is a sign of much importance is generally 
admitted, since it so quickly follows ces- 
sation of menstruation and, therefore, 
further tends to confirm the presumptive 
evidence of pregnancy. With reference 
to its etiology, one finds as many views as 
there are stars in the sky, each differing 
from the other in magnitude and brill- 
iancy even as these distant orbs of light. 
lyCt us, then, turn away fr<)m such a merry- 
go-round of medical opinion and seek to 
discover the truth in the realms of anatomy 
and physiology rather than in the domain 
of idle speculation. 

Coincident with conception, we find a 
general rise in the intra-pelvic blood 
pressure resulting in increased activity on 
the part of all the viscera therein con- 
tained which are concerned in the process 
of reproduction. Cells heretofore carry- 
ing on a passive existence now spring 
into a high state of activity. Likewise 
there occurs hyperplasia and hyper- 
trophy of tissue which is especially rapid 
in the uterine muscular elements. Nerves, 
which in the unimpregnated condition 
possess but a low grade of sensibility, 
now become highly sensitive and transmit 
readily to their respective centres slight 
disturbances which under other circum- 
stances would fail to throw them into a 
state of activity. What relation, one may 
very properly ask, exists between the 
vomiting of pregnancy and this exalta- 
tion of the nervous system ? A causal 
one, most assuredly ! 



134 



Communications. 



Vol. Ixvi 



Can one fail to realize that this is a 
symptom of pregnancy due to the change 
in the nervous equilibrium induced by 
the process of gestation? Surely not. 
Rather are the nausea and vomiting ex- 
pressions of a reflex irritation, having its 
origin at the end-organs of the uterine 
nerves, which, as we have seen, are in a 
hyperaesthetic state. As the growing 
ovum demands, day by day, an increased 
space for its development, these end- 
organs are subjected to a varying degree 
of irritation, which is transmitted to the 
centres and thence reflected out along 
the nerve filaments distributed to the 
stomach. Why this affection is of more 
frequent occurrence and of greater sever- 
ity in the first than in subsequent 
pregnancies one can readily understand 
by comparing the cavities of the primi- 
parous and multiparous organs. 

We find in the former that the uterine 
muscular walls are convex and nearly, if 
not quite, in apposition, hence the 
capacity of the organ in these females 
is relatively less. Not so the multipar- 
ous uterus, for its walls are concave and 
the capacity is further increased in length 
by one-half of an inch, owing to incom- 
plete involution on the part of Nature 
after the first pregnancy. Need we seek 
for more conclusive evidence than this to 
support our position ? Is it not plain to be 
seen that the resistance in the primipar- 
ous organ will be greater and the nervous 
disturbance more pronounced than where 
the cavity is larger, thus allowing the 
ovum to undergo its development with- 
out interference? Further, the period 
when nausea and vomiting are most apt 
to occur is in the second month, at a time 
when the growth of the uterus is princi- 
pally lateral and the villi of the chorion 
are thrusting themselves into the serotine 
or placental decidua. As to the charac- 
ter of its onset, it is usually gradual, and 
disappears in a similar manner as the 
uterus rises out of the true pelvic cavity, 
thus having quite ceased by the end of 
the fourth month. 

Concerning the symtomatology of this 
affection, it has not a few well-defined 
characteristics. The primary nausea and 
oppression experienced over the epigas- 
trium soon gives place to vomiting, not, 
however, preceded or accompanied by any 
degree of nervous depression, as is the 
case with emesis under all other circum- 
stances. The food, if any is present in 
the stomach, is expelled, not violently 



nor with any amount of retching, but 
almost as if it were regurgitated. Should 
the stomach be empty, then simply a 
little clear, normal gastric mucus is 
raised, which, as it usually occurs early 
in the morning, has given rise to the 
popular appellation of morning sickness. 
Further, if the matter vomited be food, 
it will not be found on examination to be 
sour or to have undergone decomposition, 
but in a more or less perfectly digested 
state, depending upon the length of time 
since its ingestion. As to the subsequent 
amount of nervous depression, in most 
instances it is practically nil, even when 
the vomiting is frequent and of long 
duration. This fact is very noticeable in 
some cases ; the pregnant female may 
have just finished a hearty meal — for 
impairment of the appetite is rather the 
exception than the rule — when almost 
immediately afterward she will be obliged 
to evacuate the stomach, only to turn to 
the piano and find consolation for her lost 
breakfast. Rarely does one meet with a 
case of vomiting of pregnancy where the 
female's health has materialh^ suffered, 
and this is what one would reasonably 
expect from the study of the symptoma- 
tology of the affection. 

That this digestive disturbance is a 
purely sympathetic one, is proven by the 
fact that by a strong effort of the will 
the female can not infrequently ward off 
an attack. 

Should she, for instance, have accepted 
an invitation out to dine during this 
period of gestation, she can control the 
nervous irritability by a firm determina- 
tion not to betray her condition to the 
assembled guests. It has been repeat- 
edly asked. How can a woman suffer 
from morning sickness at one period of 
gestation and not at another ? In other 
words, How is it that the attacks vary in 
severity in different pregnancies ? More- 
over, Why is it that one pregnant woman 
has morning sickness and another does 
not ? Can this be explained on the hy- 
pothesis of reflex nervous irritability ? 
Most assuredly ! 

The variability in the duration and 
severity of the affection is due to two 
factors : Greater or less irritation, and 
greater or less irritability. The question 
may here be asked, Is vomiting of preg- 
nancy a physiological or a pathological 
process ? 

It has been stated that among women 
of a strong, robust type, vomiting of 



January 23, 1892. 



Communications. 



135 



pregnancy is exceptional rather than the 
rule, as is the case in Europe and 
America. But this fact has no direct 
bearing on the case ; it goes without say- 
ing, that the stronger and less sensitive 
the nerv^ous system the less general and 
severe will be the sympathetic disturb- 
ance. One certainly is not warranted in 
stating that the vomiting of pregnancy 
is a pathological process, for it is due to 
a purely physiological cause. There ex- 
ists no morbid alteration in structure or 
function of the nerves. The irritability 
is not pathological but physiological, 
depending upon the degree of sensibility 
of the nervous apparatus. Yet it has 
been claimed by some investigators that 
this ver^' exaltation is evidence of some 
pathological lesion. Surely not. It 
were, it seems to me, as reasonable to 
declare a person's brain diseased because 
he is irritated by Wagner's music, in 
which he finds no harmony, as to declare 
that the sympathetic disturbance excited 
by pregnancy is due to some morbid 
process. 

Again, if we select two galvanometers, 
one registering the weakest electric cur- 
rent, the other equally well constructed, 
but less sensitive, we cannot say that 
the former is any more perfect than the 
latter ; they differ simply in the degree 
of their sensibility. Difference in sensi- 
bility within certain prescribed limits is 
a physiological, not a pathological fact. 
While vomiting, as Austin Flint points 
out, is not, strictly speaking, a physio- 
logical process, yet under these circum- 
stances it is far from pathological ; rather 
let us say it is the pathological expres- 
sion of a physiological process. The 
vomiting of pregnancy, unless compli- 
cated by some morbid process, never 
:gives rise to alarming symptoms or 
threatens life. If prolonged beyond the 
period of quickening, its continuance 
may be accepted as positive evidence of 
some complication, which a decided al- 
teration in the character of the vomited 
matter will usually indicate. 

Cases of pernicious vomiting call for 
diligent search for organic lesions in the 
nervous S3"stem, or structural changes in 
some of the generative or associated 
organs. That the vomiting of pregnancy 
occurs in healthy, strong women almost 
as frequently as in their less robust sis- 
ters, though in a milder form and of 
shorter duration, only confirms the view 
as to its physiological nature. The view 



advanced, that the difficulties of parturi- 
tion are proportionate to the severity and 
length of the morning sickness, one is 
scarcely prepared to accept. The gravity 
of the digestive disturbance is to be esti- 
mated by the amount of nervous irrita- 
bility, while the difficulties attending 
parturition may be classified under two 
heads : maternal and foetal. The former 
including uterine inertia, pelvic deformity 
and rigidity of the soft parts ; the latter 
abnormal size of the foetus and malposi- 
tions of the foetus. Surel}^ no such con- 
clusions are justified, for the reports from 
the large lying-in hospitals of both 
America and Europe unmistakably prove 
no such relation exists. Females who 
have suffered great annoyance from 
morning sickness have frequently as easy 
and sometimes more rapid labors than 
those who have almost wholly escaped 
this unpleasant early indication of preg- 
nancy. Therefore, in conclusion, it 
would appear from a study of this 
affection : First, that the vomiting of 
pregnancy is due to a reflex irritation 
produced by the developing ovum acting 
upon an exalted nervous system. Second, 
that it is not an affection of great gravity 
and need occasion no anxiety or alarm. 
Third, that active treatment is rarel}^ 
demanded, as it is only a disturbance 
of a few weeks at the most. Fourth, 
that the severity of the gastric trouble 
is no indication of the character of the 
subsequent labor. Fifth, that where 
the affection persists beyond the period 
of quickening, it is due to pathological 
causes, which must be discovered and 
treated accordingly. {^For discussion, 
see Society Reports. ) 



CASE OF INVERSION OF A NON-PUER- 
PERAIv UTERUS.* 

By JOHN B. ROBERTS, M. D., 

PROFESSOR OF SURGFRY IN THF WOMAN'S 
MFDICAIy COI^IvFGE OF PFNNSYI.VANIA, 

This case seems to me of interest be- 
cause of the comparative rarit}' of the con- 
dition. I give it simply as a contribution 
for clinical discussion. 

' Mrs. H., aged forty-three, in November, 1890, 
complained of having had bearing-down pain for 
some months, and a slight vaginal discharge which 
had recently become offensive. Menstruation had 
been regular, and there was no great loss of blood 



* Read before the Philadelphia County Medical 
Society^ December 23, 1891. 



136 



Communications. 



Vol. Ixvi 



at her usual periods. The woman had been mar- 
ried eight years ; had had one miscarriage, but no 
children. 

" Vaginal examination revealed a reddish mass 
protruding from the uterus through a well-dilated 
OS. As this was evidently a submucous fibroid 
tumor, a drachm of fluid extract of ergot was 
ordered to be taken three times a day, and douches 
of corrosive sublimate (1 : 4000) to be used twice 
daily. A little later the vaginal douche was 
changed to carbolic acid solution. 

"About ten days after I first saw her the patient 
was etherized, and a sloughing, friable mass re- 
moved with the fingers and forceps, aided by a 
curette. The mass was about the size of a small 
orange. The patient recovered promptly and was 
discharged from treatment in about two weeks' time. 

" Three weeks later I was sent for to see the same 
woman, who was then very emaciated, exceedingly 
week, and suflTering intense pain in the abdomen, 
with the knees flexed upon the pelvis, and with an 
exceedingly fetid, profuse, and sanguinolent dis- 
charge from the vagina. 

Pressing my hand upon the abdomen, I found 
the bladder greatly distended with urine, and upon 
investigation I discovered that she had not passed 
any water for several days. Catheterization re- 
lieved this condition, and examination by the 
vagina showed the existence of another sloughing 
fibroid tumor This was readily removed with the 
forceps and fingers. The patient recovered 
promptly, though she was still weak when last 
seen. 

" About three months later she came to my office 
exceeding pallid, with the statement that for some 
time she had been sufiering from most profuse 
uterine haemorrhages. Examination revealed 
protruding from the vulva a mass about the size of 
a small apple. Constant loss of blood was taking 
place, and the patient was so anaemic that she nearly 
fainted in my oflBce, and had to be sent in a car- 
riage to the Polyclinic Hospital. The vagina was 
packed, and the patient given full doses of quinine 
and whiskey. This was in March, 1891. After 
having been kept in bed for several days she was 
etherized, and a full examination of the uterine 
condition made. I found what I had previously 
suspected— a small growth attached to the fundus 
of the uterus which had caused inversion of that 
organ. The mass occupying the vaginal outlet and 
the vagina was, therefore, the uterus, which had 
been turned inside out, with the attached polypoid, 
fibroid tumor. I readily tore loose from the 
mucous membrane of the inverted uterus what was 
found to be two small fibroid tumors, one about the 
size of a black walnut, and the other rather smaller. 
They are shown on the plate containing the speci- 
mens, but are now shrunken from long immersion 
in alcohol. 

"An efibrt was then made to replace the inverted 
uterus by continuous pressure made with the finger 
introduced into the vagina. This was continued 
for a long time, but proved ineffectual. I consid- 
ered at the time the propriety of removing the in- 
verted uterus by performing partial or complete 
vaginal hysterectomy. It seemed to me, however, 
that it would be wise to make a further attempt at 
replacement before adopting radical measures. 
The patient was accordingly kept in bed nearly two 
weeks in order to build up her general health by 
stimulus and tonics, before making further attempts 
at invaginating the inverted uterine walls. 



" She was then again etherized, and a prolonged 
eflfort was made at replacement by means of the 
fingers and Aveling's repositor. The manipulation 
was kept up for an hour and a half, but was abso- 
lutely useless, although the pressure was made in a 
very continuous manner. The patient became sa 
weak that I feared she might die upon the table,, 
and I therefore abstained from further manipula- 
tion and again put her back to bed. 

" Two weeks later another efibrt was made to 
overcome the inversion of the womb. I was 
assisted on this occasion by Drs. Baldy, Baer and 
Anna M. Fullerton, whose counsel and aid I felt 
that I greatly needed. The abdomen was opened 
by a median incision, when the coils of intestine 
occupying the pelvis were seen united by recent 
lymph, evidently due to the traumatism of the 
previous manipulations. An endeavor was made 
to correct the condition of the uterus by means of 
strong forceps introduced through the abdomen to 
dilate the uterine neck, while pressure from below 
was made with the fingers in the vagina. Although 
these manipulations were performed by such ykill- 
ful operators as those I have mentioned, we were 
unable to make any marked impression upon the 
displaced organ. Unfortunately, I had not pro- 
vided myself with the most approved form of for- 
ceps. I then pushed through the fundus of the 
uterus a large needle carrying a strong piece of 
fishing-line to which was attached at the vaginal 
end a button of soft metal. I hoped that traction 
on this cord through the abdominal wound would, 
by means of the button pressing upon the mucous 
membrane of the uterus in the vagina, cause the 
uterus to assume its proper condition. While dila- 
tation of the inverted fundus was made by means of 
the forceps, traction was made upon the string and 
pressure upward through the vagina. The muscu- 
lar contraction of the uterine neck, however, pre- 
vented anything being gained by this manipulation, 
although the force applied was such as to finally 
cause the button to pull through the fundus of the 
uterus and to make its exit into the pelvis. After 
spending considerable time in these unsuccessful 
attempts, I finally did a partial vaginal hysterec- 
tomy, removing the inverted portion high up and 
stitching the edges of the uterine wall at the fundus 
together. This procedure was resorted to only 
after the patient had been under ether for three 
hours and was so overcome by shock that her con- 
dition was extreme. She did not react, her tem- 
perature not rising above 95° F., and she died 
within a few hours. 

" The abdominal wound was then opened, and a 
very small amount of blood found near the stump 
of the uterus. Evidences of non-septic traumatic 
peritonitis due to the previous manipulation were 
present, as has been stated in the account of the last 
operation." 

In looking back upon this case, I can- 
not but feel a sense of regret that the 
more radical operation of vaginal hyster- 
ectomy was not done at the time that the 
patient was subjected to operation for 
removal of the tumors causing the inver- 
sion. My desire to avoid an operation 
accompanied by shock and haemorrhage 
at the time she had been so depressed by 
violent and repeated flooding, made me 
adopt what at the time seemed a less radi- 



January 23, 1892. 



Society Reports. 



137 



cal course. The extreme difficulty of 
dilating the uterine neck in cases of in- 
version was not appreciated by me until 
I found my attemps at replacement futile. 
(^For discussion, see Society Reports?) 



SOCIETY REPORTS. 



PHIIvADBlvPHIA COUNTY MEDICAL 
SOCIETY. 



Stated Meetings December g and 2j, i8gi. 

The President, John B. Roberts, M. D., 
in the chair. 



Dr. T. B. Schneideman read a paper on "Ophthal- 
mia Neonatorum as a Cause of Blindness." (See 
p. 129.) 

DISCUSSION. 

Dr. George E. de Schweinitz: Unfortu- 
nately, I came into the room too late to hear the 
first portion of this paper. There is no question 
that bichloride of mercury, under ordinary circum- 
stances, is an excellent germicide, but in spite of 
the good results which have been reported, I am 
very much against the use of strong solutions of 
this drug in ophthalmia neonatorum. It is true that 
investigations have shown that a solution of 
1 : 10,000 will retard the vitality of certain bac- 
teria — for example, staphylococcus pyogenes au- 
reus ; but in ophthalmia neonatorum and in gonor- 
rhoea! ophthalmia, the characteristic behavior of 
the gonococci is their residence within the living 
cells, and under these circumstances I do not believe 
it is possible for irrigations of bichloride of mer- 
cury to act in their ordinary germicidal function. 
Moreover, I am convinced from clinical and direct 
histological experience that strong solutions of sub- 
limate have a distinctly deleterious effect. I need 
not refer at any length to the disastrous results to 
the cornea that have occurred from the use of this 
drug in strong solutions during cataract operations. 
Fspecially is this true when they have been em- 
ployed to irrigate the anterior chamber. It is of 
the highest importance during ophthalmia neona- 
torum that the epithelial surface of the cornea 
shall be kept intact ; and while I am not prepared 
to say that the use of a strong solution can actually 
produce an abrasion, I am well satisfied that it adds 
distinctly to the dangers of the case. A recent 
European investigation in regard to the effect of 
this drug upon the cornea has demonstrated its 
capacity for producing changes that might well 
make one hesitate in its employment in very active 
strength. It should be remembered that during the 
height of an attack of ophthalmia neonatorum, the 
resisting power of the cornea is materially de- 
creased, and hence very irritating solutions, no 
matter of what composition, are to be deprecated. 
I beg to be understood in this matter ; I do not for 
one moment dispute the value of bichloride in puru- 
lent affections of the conjunctiva, but I deem it in- 
advisable to use the drug in strong solution, and be- 
lieve that it is impossible to employ it mjdy in such 
strength that it will act as a true germicide. More- 
over, it has been shown that bacteria in the presence 
of albumen have the power to reduce bichloride of 



mercury to calomel. Now, calomel, to a certain 
extent, is a germicide, but must have very inferior 
qualities under these circumstances. There does 
not seem to be any objection, for cleansing and 
antiseptic purposes, to a strength of 1 : 10,000 
(Cohn, in his recent book, recommends (1 : 5000). 
A convenient strength is a grain to the pint — i. e., 
about 1 : 7500. In the Philadelphia Hospital, as 
ray colleague, Dr. McKelway, will testify, we are 
in the habit of using alternately a solution of 
bichloride of mercury, a grain to a pint, and a sat- 
urated solution of boric acid. If the cleansings 
are made hourly, first one and then the other 
drug is employed. Boric acid is without germicidal 
value, but it is an excellent slightly astringent 
cleansing agent. 

Keferring to the other portions of the treatment 
advocated by the Doctor in his paper, I beg to agree 
with him most emphatically — i. e., with his use of 
nitrate of silver. It should not be employed in the 
earlier stages, or in any stage in which there is much 
infiltration and the formation of false membrane ; 
but when there is free secretion of yellow pus, 
when the lids are supple, when the conjunctiva is 
covered with hypertrophied papillae and positive 
granulations, nitrate of silver, in the strength of ten 
to fifteen grains to the ounce, is the germicide par 
excellence. Applied carefully with a cotton mop, and 
properly neutralized, if strong solutions are em- 
ployed, any irritating effect upon the cornea may be 
avoided. It acts in three ways : as a germicide, 
because it is at the same time a superficial caustic, 
destroying a layer of epithelial cells, and probably 
the bacteria which are contained within them ; as 
an astringent ;^ and as an alterative, using that 
term to imply its efficiency to alter the nutrition of 
a mucous membrane which is inflamed. 

In regard to the other solutions which various 
surgeons have employed in this condition — carbolic 
acid, aqua chlorini, weak solutions of nitrate of 
silver, etc — my experience is limited. They come 
to us endorsed with high authority. In regard to 
one drug, however, I wish to place myself on 
record — namely, pyoktanin. I hope that no one 
will treat cases of purulent ophthalmia in the 
newly-born with this drug. 

Finally, I may say that, in my belief, the 
more or less continuous application of cold is of 
great value in the earlier stages. The essayist has 
referred to atropine and eserine, evidently giving 
his preference to the former drug, should corneal 
ulceration indicate its use. I would reverse the 
order and place eserine first, provided no iritic 
complication contra-indicates its instillation. 

Dr. Charles H. Thomas: There is one sug- 
gestion growing out of what Dr. Schneideman has 
said which seems worthy of further amplification — 
that is, the question of some legal enactment which 
shall help to prevent the blindness which is so fre- 
quently the result of ophthalmia neonatorum. Such 
a law has been enacted by the State of New York, 
and there has been some attempt to establish one 
in the State of Pennsylvania. It seems to me that 
there is no place in the State of Pennsylvania 
where a movement with this object in view could 
be more effectively inaugurated than in this society. 
It is my hope that all who have heard this very 
able and true statement, will resolve themselves 
into a committee to further the enactment of such 
a law as has been suggested. There is no question 
as to the propriety of compelling midwives to re- 
port such cases, and I am not sure but that we 



'38 



Society Reports. 



Vol. Ixvi 



could go further with propriety aod require medi- 
cal practitioners to report these as well as other 
cases of infectious diseases. There are, of course, 
many physicians who should not be put to this 
trouble, but there are others who see but few such 
cases, and it would have a wholesome moral effect 
upon all to feel that this disease was dignified 
enough to require a report to the Board of Health. 

Dr. Charles P. Noble : I will speak upon this 
subject from the standpoint of the obstetrician 
rather than from that of the ophthalmologist. There 
are several points which interest me. I am much 
pleased to tind that so long ago as 1807, some one 
had insisted upon the fact that the treatment of 
ophthalmia nemaiorum should begin with the mother. 
This has been insisted upon by various obstetricians, 
and I have myself long felt the importance of it. 
It has been a rule with me for years to pay atten- 
tion to the question of vaginal discharges in preg- 
nant women. If there is a free vaginal discharge, 
even though no complaint is made of its irritation, 
I have always made a local examination, and if 
vaginitis were found to be present, have insisted 
upon systematic local treatment. I think that this 
is a most important point, and one that is even 
more important than the early treatment of the 
eye. If we can prevent infection, we do not need 
the early treatment of the ophthalmia. Some 
years ago, when connected with the Lying-in 
Charity, I saw quite a number of cases, and I have 
had several in private practice. I may say that 
among these cases there was only one in which an 
eye was lost. This occurred in a syphilitic infant. 
In this case, Dr. Lautenbach acted as a consultant, 
so that the child had everything that ophthalmolo- 
gical science could do for it. The treatment used 
at the Lying-in Charity was frequent irrigation 
with a saturated boric acid solution. When the 
discharge was very free, it was used as often as 
every half hour, together with silver nitrate solu- 
tion (ten grains), used twice daily. It was thought 
that advantage was derived, particularly when the 
swelling was great, from the application of cold 
compresses. 

Speaking still from the standpoint of the obstet- 
rician, I should advise that the practitioner always 
avail himself of the counsel of an oculist in the 
management of such cases. He will thus be saved 
the anxiety and regret of occasionally losing an 
eye and forever injuring the prospects of the infant. 

On motion, the following committee was ap- 
pointed to confer with the State Board of Health 
relative to this subject : Drs. T. B. Schneideman, 
C. H. Thomas, Benjamin Lee, Edward Jackson, G. 
E. de Schweinitz. 

Dr. T. Eidgway Barker read a paper on 
Some Mooted Points Concerning the Vomiting of 
Pregnancy." (See page 133 ) 

DISCUSSION. 

Dr. Charles P. Nuble : Dr. Barker prefaced 
his remarks by saying that he should not take up 
the matter from a theoretical standpoint, and that 
he would not present the theories held by others, 
but would study it from the standpoint of anatomy. 
I think, however, that the theory he advances, 
that the vomiting of pregnancy is reflex in its 
origin, due to the growth of the ovum, is a very 
old one. The are a great many theories to account 
for this affection. Among the most important is 
that held by Grailly Hewitt— namely, that the 



vomiting is due to induration or inflammation of 
the cervix or to ) flexion. Dr. Hewitt has gone 
very fully into the subject, and while we may not 
agree that this is the only cause of vomiting of 
pregnancy, yet anyone who has studied the large 
number of cases which he reports, cannot help but 
feel that there is a close relationship between exag- 
gerated flexion of the uterus and also induration 
of the cervix due to inflammatory trouble and the 
vomiting of pregnancy. I have myself not in- 
frequently seen this combination. I have also 
seen vomiting associated with more or less en- 
dometritis, and with induration and thicken- 
ing of the cervix which was present before preg- 
nancy took place. Again, the uterus may be 
more or less fixed by old inflammatory trouble, 
and when it becomes pregnant it is prevented from 
rising into the belly, as is usually the case, and in 
that way also the reflexes are increased. Again, 
we know that the uterus may be retroverted and 
caught under the promontory of the sacrum, and 
may then be prevented from rising into the abdo- 
men, and may produce such reflex symptoms. I am 
satisfied that old inflammatory trouble in the pelvis 
has a great deal to do with the vomiting of preg- 
nancy. It, however, simply acts to increase the 
reflexes from the uterus. 

A more recent theory, and one supported by sq 
eminent an authority as Kaltenbach, is that the 
vomiting of pregnancy is hysterical. I think that 
there is no doubt that a certain number of cases are 
due to hysteria. But I would not go so far as to 
hold that all cases are due to this cause. 

There is no question that not only do we have a& 
a result of pregnancy changes in the pelvis, but 
the whole body of the woman increases in size and 
undergoes changes. The entire vascular system 
becomes hypertrophied, and the heart also becomes 
enlarged. We know that pregnancy changes the 
entire form of the woman. The entire system is 
involved, and we can readily understand that con- 
gestion of the alimentary canal can be brought 
about. We all know that the nervous system in 
the pregnant woman is extremely irritable. It re- 
sembles the nervous system in children. For this 
reason, irritation from the pelvis which ordinarily 
would not be sufficient to cause reflex symptoms, 
can do so at this period. 

The Doctor assumes that the reason why primi- 
parous women are more apt to have vomiting than 
multiparse, is because the uterus of the multiparous 
woman is larger, and therefore the growth of the 
ovum would not cause so much distention. There 
is no question concerning the fact, but the expla- 
nation is not satisfactory. 

It is true that the uterus of the multipara is larger 
than that of the primapara. It is also true that 
the abdominal walls are more relaxed, giving a 
less degree of intra-abdominal and intra-pelvic 
pressure. The woman is better prepared for preg- 
nancy, having already been pregnant. The mental 
condition is probably not so disturbed, and the 
emotions not so excited in the multipara. All 
these points must be considered. Moreover, it 
must not be forgotten that the uterus grows as well 
as the ovum, so that it is at least questionable 
whether the ovum distends the uterus. Does it 
not simply fill it ? 

It seems to me that the practical outcome of 
the whole matter is that, given a serious case of 
vomiting in pregnancy, it is the business of the 
practitioner to find the cause of the trouble. 



January 23, 1892. Selected Formulce. 



139 



Whether it is extrinsic purely — due to indigestion 
or uraemia ; or whether due to excitability of 
nervous system or to hysteria ; or whether some 
pelvic lesion is the source of irritation. If this 
plan of treatment were followed, better results 
would he obtained. 

Dr. John B. Roberts reported a " Case of Inver- 
sion of a Non-Puerperal Uterus." (See p. 135.) 

DISCUSSION. 

Dr. Charles P. Noble : It has been my expe- 
rience to see two cases of inversion of the uterus, 
and in both cases the attempts at reduction failed. 
The first case I saw at the Lying in Charity, and 
was, I think, a long-standing post-puerperal case. 
Manual reduction was tried, but abandoned for the 
reason that the uterus was soft and macerated. In 
this case the uterus was amputated and recovery 
occurred. The second case I saw with Dr. Kelly 
and was present at an operation in which he opened 
the abdomen. The abdominal neck of the inver- 
sion was dilated with forceps, and manipulations 
were made with one hand in the belly and one in 
the vagina, but the effort at reduction failed- In 
that case, Dr. Kelly took out the whole uterus, and 
the patient made a good recovery. 

Speaking of the treatment, Dr. Eoberts did not 
mention one method which has met with excellent 
results. It is the method of gradual reduction ad- 
vised by Dr. Aveling. Constant pressure on the 
inverted uterus is made through a repositor, which 
is attached by elastic bands to a support about the 
waist. A large series of cases has been reported in 
which this method has been employed with almost 
universally successful results. Of course, in some 
cases the presence of adhesions will prevent the 
reposition of the uterus. The reasons for the suc- 
cess of this plan is plain. The problem is to over- 
come the resistance of the muscular tissue in the 
upper part of the cervix, and to make it relax and 
dilate. This tissue is resistant enough to tire out 
the muscles of the surgeon when attempting rapid 
reduction, but gives way before the steady action of 
the rubber tapes. It seems to me that in a case of 
any standing, attempts at rapid redaction are inad- 
visable, and are liable not only to fail but to do 
harm. It seems to me that in a long-standing case 
of inversion, the thing to do would be to pack the 
vagina with an astringent tampon, and afterward 
apply the gradual method of Aveling. If that did 
not affect reduction, the best thing would be to do a 
radical operation. The question arises whether it 
would not be better to remove the ovaries and 
tubes, which would bring about a cessation of the 
haemorrhage. This would be a simple matter, and 
I think that reduction in the size of the uterus 
would take place. If this were not done, I think 
that a simple amputation of the protruding mass 
would be quite a feasible operation ; but, of course, 
the danger there would be that after the mass of the 
uterus was removed the remainder would reinvert 
itself, and possibly infect the peritoneal cavity. 
This could be obviated by using transfixion pins. 
My own feeling would be in favor of removal of 
the tubes and ovaries, and later to do a vaginal 
hysterectomy, if necessary. 

Dr. Roberts: In this case the uterus was not 
soft, but was as hard as a fibroid tumor. The tight- 
ness with which the neck grasped the inverted 
uteurs was something astonishing. 

I am somewhat familiar with two other cases of 
inversion of the uterus. One happened some years 



ago in the country. The practitioner did not know 
what was protruding after labor, and sent for Dr. 
Levis, who, after a good deal of manipulation, 
pushed the inverted uterus back. The second was 
also, I think, a puerperal case, and happened not 
long ago at the Woman's Hospital of Philadelphia ; 
in this instance, the physician was able, after 
manipulation for several hours, to replace the 
uterus. It was perhaps the knowledge of these 
cases which led me to make such prolonged attempts 
at reduction. I see now that it was unwise, and I 
agree with Dr. Noble that if such a case again came 
under my care, I should be inclined to first remove 
the ovaries, and if that were not sufficient, to make 
a total hysterectomy. This patient was in extremis 
at the time, and I did not feel justified in doing a 
too radical operation when I removed the two small 
tumors. 



SELECTED FORMULA. 



INTESTINAL ANTISEPSIS. 

The following formula is recommended 
by Dujardin-Beaumetz as a good intes- 
tinal antiseptic : 

1^ Salol, 

iX^ Salicylate of bismuth, 

Bicarbonate of sodium, aa 150 grains. 
M. and divide into xxx powders in capsules. S, One 
before breakfast and one before dinner. 

— Les Nouveaux Remedes, November 
8, 1891. 



RESORCINE IN DIARRHOB^A. 

Menckle {Ceiitralbl. furklm. Med.)w'ho 
has, with gratifying success, employed 
resorcine in the treatment of diarrhoea in 
children and adults, highly recommends 
the following : 

T>. Pure resorcine gramme 1. 

-Qy Distilled water grammes 90. 

Simple syrup " 60. 

Camphoratfd tine, of opium... .gramme 1. 
M. S. A dessertspoonful every two hours. 
For children b th the resorcine and the paregoric should be 
reduced to 0.50 granmien, and then the potion can be given in 
teasp onful doses every two hours. 

— Le Bulletin Medical, November ii, 
1891. 



TUBERCULOSIS. 

Arthaud proposes the following mix- 
tures in the treatment of tuberculosis, 
especially in the second stage of the dis- 
ease : 



a. p; Iodide of potassium grammes 10. 

Alcohulate of tannin " 20. 

Glycerine " 150. 

Alcohol " 50. 

Banyuls wine q. s. for 1 litre. 

M. S. A glassful after each meal. 

b, 1^ Fluid extract of rhatany (50 per 

cent ) grammes 30. 

SjTup of mulberries " 250. 



M. S. A tablespoonful 5 tim^s a day, to be accom- 
panied by the administration, night and morning, of 10 droj s 
of tincture of iodine in milk. 

— Le Progrhs MSdical, December 5, 
1891. 



140 



Selected FormulcB. 



Vol. Ixvi 



FUCHSINE IN CHRONIC ULCERS. 

After washing of the ulcers with warm 
water, they should be touched with the 
following solution, as recommended by 
Rosenberg : 

T> Distilled water grammes 200.00. 

Alcohol (90 per cent.) " .10 00. 

Fuchsine " 0.70. 

The ulcers are to be covered with gauze moistened in the 
same solution. The drug is said to diminish pain and suppura- 
tion, and to cause a rapid cicatriza ion. 

— Le Bulleti7i Medical, November ii, 
1891. 

FOR FISSURES OF THE TONGUE. 

The following solution is applied, by 
means of a pencil, in the treatment of 
fissures of the tongue : 

"O Phenic acid grammes 2.50. 

jQks Tincture of iodine. 

Glycerine aa " 12.50. 

— Allgemeine med. centr. Zeitung ; Le 
Bulletin Medical, Nov. ii, 1891. 

IvARYNGEAIv AFFECTIONS. 
Schnitzler recommends the following 
mixture to be blown into the cavity of 
the nose and of the naso-pharynx, as well 
as into the larynx, in diseases of those 
parts : 

a. ^ Subnitrate of bismuth grammes 10. 

8ugarof milk " 10. 

Balsam of Peru " 2. 

M. 

The same author extols the following 
solution as a local application : 

d. Clilovhj'drate of cocaine grammes 0.50. 

Balsam of Peru " 10 dO. 

Alcohol " 10.00. 

Aromatic essence drops 5. 

Schnitzler prefers the balsam of Peru to phenic acid, creasote 
or creoline. on account of its agreeable las^e. 

— Revista de Ciencias Midicas de Bar- 
celona, December lo, 1891. 

TOPICAL APPLICATIONS IN DIPH- 
THERIA. 

Dr. George W. Peck writes in The 
Medical News that he has found the fol- 
lowing to be an efficient application in 
the treatment of diphtheria. It can be 
employed in all stages of the disease, 
without danger to the patient. It should 
be applied often and thoroughly, by 
means of a brush or cotton swab, until 
the diseased membrane entirely disap- 
pears. In connection with this remedy 
he gives as much brandy as the patient 
will bear, and such other remedies as 
may be indicated : 

T>. Acidi boiici 5j . 

-Qo Acidi lactici f 5j. 

Glycerini f Sjss 

Aquae dest f Sijss 

Liq ferri subsulph f Sjss. 

M. This solution may be used in full strength or 

diluted with water, as each case may require. 



SULPHUR IN DISEASES OF THE SKIN. 

Zadeck, of Kiew, who has made an 
especial study of the therapeutic uses of 
sulphur in cutaneous affections, recom- 
mends the following preparations : 

For inveterate cases of acne 7vsacea and 
seborrhoeic eczema : 

a. ^ Flowers of sulphur grammes 2.50. 

Ointment of benzoate of zinc 

(or vaseline) " 30.00. 

M. S External use. 

^ Flowers of sulphur, 
Spirit of camphor, 
Gljcerine, 

Kose-water aa grammes 10. 

M. S. To be applied over diseased parts, on retiring. 
This is especinlly recommended in acne rosacea of the nose, 
and also of the face. 

For seborrhcea of the scalp : 

T>. Floweis of sulphur grammes 2C0. 

XV Oil of sweet almonds " 90. 

Glycerine " 90. 

M. S. Externally applied ; to be shaken before using 

For hypei'hydrosis of the hands, axilla, 
feet and other parts : 

a. ^ Flowers of sulphur grammes 2.00. 

Powder of arrow-root *' 15 00. 

Salicylic acid " 0.50. 

M. S. To be powdered over affected parts. 

b. 9^ Flowers of sulphur grammes 8 

Sulphuric ajther " tO. 

Eectified alcohol " 60 

M. S. To be applied ovt r diseased parts. 

— Le Bulletin Medical, December i6, 
1891. 

SYPHILITIC OTITIS. 
Laurence Turnbull recommends the 
following prescriptions in the constitu- 
tional treatment of sj^philitic diseases of 
the ear : 

a. ^ Red iodide of mercurj' 15^/2 grains. 

Iodide of potassium 13 drachmt. 

Distilled water 2 tluid ounces. 

M. Dissolve and filter, then add simple syrup until 
the whole measures 50 fluid ouDces S. One teaspoonful 3 
times a day. 

i. ^ Bichloride of mercury of a grain. 

Arsenious acid ^ " 

Pyrophosphate of Iron 6 grains. 

11 . and make xxiv pills. S. One ^ilfs times a day. 

— Annals of Ophthalmology and Otology ^ 
January, 1892. 

TREATMENT OF SCABIES. 
Prof. Kaposi, of Vienna ( Wiener med. 
Wochenschr. ; Gaceta medica catala?ia, 
No. 7, 1891), recommends the following 
salve as most efl&cacious in the treatment 
of scabies : 

T> Adipis grammes 100. 

XV Saponis " 50. 

Naphthol, B " 15. 

Cretae pulverizat " 10. 

The treatment should not necessarily 
extend over twenty-four hours. If there 
be pruritus present the amount of 
naphthol must be reduced ; and if eczema, 
still less must be used, as the naphthol 
determines an active irritation. 



January 23, 1892. Ei 
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^lal, 141 

LEADING ARTICLE. 

THE ACTION OF ERGOT AS A HEMO- 
STATIC IN UTERINE HEMORRHAGE. 

Whatever may be our knowledge at 
present of the physiological action and 
therapeutic value of ergot, it is certain 
that many essential points regarding this 
interesting drug remained to be clearly 
explained experimentally and clinically. 
Opinion appears to be equally divided on 
the question of the action of ergot upon 
the circulation, for in looking over the 
literature of the subject we come across 
a mass of evidence replete with contradic- 
tory statements. 

Thus, for instance, in regard to the 
effect produced by ergotine on the arterial 
pressure : First, the researches of Vogt, 
Holmes, Kohler, Eberts and H. C. Wood, 
which seem to show a decided increase ; 
second, the results obtained by Herzmann, 
Borescha, Madelin and Wernich, showing 
a lowering of pressure ; third, the investi- 
gations of Markwald, indicating that the 
blood pressure is neither increased nor 
diminished. 

It is well known that ergot or its essen- 
tial alkaloid exercises in haemorrhage a 
decided action ; that is, under its influ- 
ence the flow is checked. How this phe- 
nomenon is brought about has not been de- 
finitely established. Leaving aside, for the 
time being, a centric vaso-motor influence 
(an influence which, according to most 
authorities, is not exercised by the drug), 
and referring especially to the effects pro- 
duced by the remedy on uterine haemor- 
rhage, it is apparent that the drug exerts 
an action on the uterine vessels and nerve 
structures. This appears to be sustained 
by the recent experiments of Kllinger. 
In normal conditions, it has been found 
that asphyxia causes peristaltic contrac- 
tions of the uterus, that . they are even 
observed in curarized animals, and that 
they are prevented by previous section of 
the spinal cord. Asphyxia under these 
latter circumstances is powerless to excite 
the organ into activity. On the contrary, 



142 



Editorial. 



Vol. Ixvi 



ergot, which, under ordinary circum- 
stances, is able to act upon the uterus as 
an oxytocic, retains the same power after 
previous division of the medulla spinalis 
— an indication that the action of the 
drug is a peripheral one. Ergot acts, 
therefore, directly upon the spinal cord 
or uterus ; that it is upon the latter seems 
evident in the fact that it produces con- 
tractions in the excised organ. This 
admitted, the drug, to diminish haemor- 
rhage, must directly influence the uterine 
muscular fibre itself or else produce con- 
striction of the arterioles. Neither view, 
however, is accepted by EUinger, and 
following the opinion of Markwald, re- 
ferred to already, to the effect that under 
the influence of the drug the blood pres- 
sure . remains intact, he regards the hae- 
mostatic action of ergot under a new and 
certainly untenable light. He believes 
that the remedy acts upon the blood itself, 
rendering it coagulable at more or less 
susceptible points of the vascular system. 

The most recent and a very valuable 
contribution to the study of the actions 
of ergot is that of Hemmeter, published 
within a few months. The experimental 
investigation was carefully carried out by 
the author, and from the results obtained 
he finds, among other facts, that ergot 
increases the blood pressure, diminishing 
at the same time the number of cardiac 
pulsations. The increase was generally 
preceded by a primary fall of pressure, 
the unusual rise occurring not only in 
normal animals but also in those in which 
the heart was previously isolated from all 
nervous connection by section of the 
pneumogastrics and spinal cord. These 
results appear to corroborate those ob- 
served by Holmes, Eberts, Wood and 
others, and it is evident that the rise of 
arterial pressure is dependent upon an 
action of the drug on the heart or on the 
arterioles. From a purely physiological 
point of view, if the arterioles are made 
to contract, the blood pressure rises, but, 
at the same time, the increased pressure 
stimulates the vagi centres in the medulla 



oblongata, in consequence of which the 
pulse-rate falls, and thus we have the 
curves of the pressure and the pulse 
running in opposite directions. When 
this takes place it is assumed by physiolo- 
gists that the change in the pressure is 
due to the arterioles. This is precisely 
what occurs under the influence of ergot, 
according to Hemmeter, and he, there- 
fore, concludes that the drug produces an 
increase of the arterial pressure by an 
action upon the arterioles and not upon 
the heart. 

Practically we know from clinical ex- 
perience that ergot is not only an excel- 
lent oxytocic, but a most valuable haemo- 
static ; that it does good in almost all 
kinds of haemorrhages. But the question 
at issue, whether this influence is due to 
an action of the drug on the arterioles, as 
is generally held, or whether it is due to 
an alteration on the blood itself, as is 
believed especially by EUinger, remains 
unsettled, although it seems clear that 
the view of EUinger is incorrect. 



THK VISITING NURSE SOCIETY OF 
PHII.ADELPHIA. 

There is a little society in Philadelphia 
which is accomplishing, in a quiet way, 
a most important and noble piece of work, 
and which deserves not only the hearty 
support of the charitably disposed, but 
emulation in every cit)^ and town in the 
country. 

The chief objects of the society, as 
stated in the little pamphlet recently 
issued, are : First, to give a good nurse 
for a short visit to persons of means who 
can afford to fully pay for this care, but 
do not require the entire time of a trained 
nurse ; second, to send an ' ' Outside ' ' 
nurse to a family in moderate circum- 
stances where the service can be paid, 
but where there is no one to attend the 
sick person ; third, to provide fully trained 
nurses for the sick poor, that by skilled 
care recovery may be hastened, and con- 
tagion and other evil consequences 
avoided. 



January 23, 1892. 



Book Reviews. 



143 



It is the desire of the society to work 
tinder the orders of physicians among 
such patients as are neither suitable cases- 
for hospitals nor able to obtain proper 
care at home. The nurse will visit each 
case once or twice a day, as may be re- 
quired, and in extreme necessity will 
remain all day when possible. A moder- 
ate charge is made for each visit. As the 
nurses make visits daily, it is impossible 
for them to undertake contagious dis- 
eases. 

Special nurses are provided for obstetric 
cases. 

The society hopes for the co-operation 
of physicians both to help the destitute 
and those, in narrow circumstances, and 
to establish among them a higher stan- 
dard of hygiene. 

As an evidence of the good work accom- 
plished, we find by the report of the 
society that during the five years of its 
existence there were attended 2818 cases, 
and 35,703 visits made. 

Nurses are furnished under the follow- 
ing terms : — 

1 . A visiting nurse is furnished without 
charge to those unable to pay for her 
service. 

2. From those able to give the car fare, 
it is expected, being ten cents a visit. 

3. For those in comfortable circum- 
stances a visiting nurse can be furnished, 
but the charge must, in such cases, fully 
cover the expense to the society, fifty 
cents or one dollar a visit, according to 
the time required. 

4. The ' ' Outside Nurses ' ' mentioned 
in this report must be paid by the patient 
according to agreement, as the society 
has no connection with them except 
keeping their names on file. 

5. Visiting nurses will remain with a 
patient for the first twenty-four hours 
after a major surgical operation, and will 
visit after that daily as required. Should 
a patient need continuous care, an outside 
nurse must be engaged and paid for by 
the patient. 

6. The hours of the nurses are from 
eight o'clock in the morning until eight 
at night. After that time they cannot 
respond to calls. 

7. The nurses will visit in the morning 



those cases which have been reported the 
previous day, while those coming to the 
office before twelve o'clock will receive 
attention that afternoon. 

8. The nurses are for the use of the 
public, and it is desired that physicians 
and others interested in the sick shall 
send for them. The service should be 
paid for whenever possible, as the society 
is supported entirely by charity. 

We hope that the evident need of such 
a society in every large community, and 
the splendid work that has already thus 
been accomplished in this city, will be the 
means of stimulating others to follow in 
its footsteps. It is only when we or those 
near and dear to us are very ill, and need 
skillful attention, that we fully appreciate 
the invaluable offices of the Trained 
Nurse — the greatest luxury in medical 
practice of the century. 

BOOK REVIEWS. 



AGE) OF THE DOMESTIC ANIMALS : BE- 
ING A COMPLETE TREATISE ON THE 
HORSE, OX, SHEEP, HOG AND DOG, 
AND ON THE VARIOUS MEANS OF 
DETERMINING THE AGE OF THESE 
ANIMAI/S. By Rush Shippen Huideko- 
PER, M. D., Veterinarian (Alfort, France); 
Professor of Sanitary Medicine and Veteri- 
nary Jurisprudence, American Veterinary Col- 
lege, New York, etc. Illustrated with 200 
engravings, 8vo, 225 pp. F. A. Davis, pub- 
lisher (Philadelphia and London), 1891. 
Price, ^1.75. 

The appearance of this work is an inci- 
dent of importance to veterinarians, and 
horse and cattle owners and dealers. It 
is the first existing treatise upon the sub- 
ject in the English language. 

The author, in the preparation of the 
book, states that he has "attempted to 
prepare such a book as he feels would 
have been of interest and service to him- 
self in his association with animals as 
a layman, and would have aided his 
studies and appreciation of the anatomy 
of the teeth, dentition, and means of 
determining the age. He hopes, also, 
that this work will furnish to students 
and veterinarians, knowledge which will 
aid in surgical operations on the mouth." 

He has drawn freely from the French, 
German and English sources, both in 
text and illustration. The book is well 
planned, clearly written and printed, and 
is an excellent exposition of the subject. 



144 



Periscope, 



Vol. Ixvi 



A, B, C OF THE SWEDISH SYSTEM OF 
EDUCATIONAL GYMNASTICS. A PRAC- 
TICAL HAND-BOOK FOR SCHOOL 
TEACHERS AND THE HOME. By Hart- 
yiG NissEN, Instructor of Physical Training 
in the Public Schools of Boston, Mass., etc. 
With 77 illustrations. i2mo, 107 pp. F. A. 
Davis, publisher (Philadelphia and London), 
1891. Price, 75 cents. 

In the teaching of Swedish gymnastics 
. the author has found that the treatises on 
the subject for the most part are not suf- 
ficiently practical to be of use as a guide 
to inexperienced teachers. In the prepa- 
ration of this little book he has avoided 
the use of technical terms, and has en- 
deavored to furnish plain answers to the 
most frequent questions, besides giving di- 
rections and illustrative wood-cuts for 
exercises for children of different ages. 
The first two chapters contain questions 
and answers such as have been most fre- 
quently put to the author in his nearly 
fourteen years' experience as a teacher of 
gymnastics, and these two chapters will 
give a very satisfactory idea of the foun- 
dation of the ' ' Swedish System of Gym- 
nastics." Other chapters contain what 
are termed prescriptions for daily lessons 
arranged somewhat as follows : 

Five daily orders of exercises for sec- 
ond and third class of Primary Schools. 
Six daily orders for the first class of the 
. Primary Schools. Seven daily orders for 
the fifth and sixth class of the Grammar 
Schools. Nine daily orders for the third 
and fourth class and fifteen for the first 
and second class of the Grammar Schools. 
The book seems admirably to fulfill the 
purposes for which it was written. 



TREATMENT OF BILIARY LITHIASIS. 

Dr. Dujardin-Beaumetz {La Semaine 
medicate , No. 51, 1891), employs as 
cholagogues : 

1. R Euonvmin "| . _ „ , 

Saponis medicinal / grammes 2 (grs. xxx) 
SufiBcient for twenty jjills. Take one pill morning and 

evening. 

2. p; Sodii salicylic grammes 15. 

Aqua; " 250. 

A dessertspoonful after each meal. 

For the gall-stone colic one may try 
large doses of olive oil (200 grammes, 
— fl. I vij— at a time). If this fail, then 
he advises hypodermic injections of 
atropine and morphine, according to the 
following formula : 

T>. Morpbise sulpliat cgm. 10. 

-LM Atropi^ snl|.hat " 1. 

Aquae sterilizat grammes 20. 

Inject a (Pravaz) syiingeful of this solution. 



PERISCOPE. 



THERAPEUTICS. 



COCA AS A PROPHYLACTIC AGAINST 
INFLUENZA. 

Dr. Sajous writes in the Satellite : The 
nature of influenza, the marked debility 
induced hy it, and its sequelae, all point 
to a remarkable depression of the gen- 
eral system. During its presence in the 
country, the prevalence and severitj^ of 
other acute diseases were largel3ancreased 
and the mortality from all other causes 
atigmented. This condition of affairs 
continued for some time after the subsi- 
dence of the epidemic. 

The value of coca as a tonic to antag- 
onize any tendency to adynamia is too 
well known to require elaboration here. 
Its therapeutical effects tend to build up 
precisely what influenza tends to destroy 
— a fact instanced by the use made of 
coca leaves by the natives of Bolivia and 
Peru, which renders them capable of 
undergoing the greatest possible physical 
strain, and that frequently with sparse 
nourishment. This remarkable tonic 
action of coca in medical therapeutics has 
further been tested by Brown-Sequard, 
Dujardin-Beaumetz, Bell, Bouchut, A. 
McLane Hamilton, A. E. McDonald, H. 
M. Lyman, I. N. Danforth, P. S. Conner, 
and many other eminent physicians, too 
numerous to mention in the space at our 
disposal. 



TREATMENT OF ANGINA PECTORIS BY 
COCAINE. 

In a paper in the Revue de Medicine, the 
author strongly recommends the use of 
cocaine in angina pectoris, in the dose of 
}4 to yi of a grain three or four times 
daily. He quotes four cases of this dis- 
ease which were benefited greatly by this 
treatment. If the attacks do not cease 
immediately after taking the remedy, 
they completely yield to it, however, in 
about three days. Under its use the 
pulse becomes slower but fuller, and the 
quantity of the urine is augmented. The 
author refers to some observations pre- 
viously made by him, which appeared to 
show that the inhalation of oxygen in 
this disease did much good ; he therefore 
suggests that it should be tried in con- 
junction with the internal administration 
of cocaine. — Med. Chronicle. 



January 23, 1892. 



Periscope. 



145 



A NEW RBMEDY FOR PHTHISIS. 

Hardly a week passes without some 
fresh drug being proposed as an infallible 
cure for phthisis. This time the remedy 
is monochlorophenol, recently prepared 
by Signor Tacchini, a chemist of Pavia, 
and tried by Dr. Passerini, of Casate- 
Nuovo. The drug is a powerful anti- 
septic, free from the disagreeable odor 
and from the caustic and irritant action 
of the related compound, trichlorophenol. 
It is recommended as an inhalation in 
various affections of the respiratory pas- 
sages, and particularly in pulmonary 
tuberculosis. Monochlorophenol is very 
volatile, giving off vapors much heavier 
than air, which are, it is supposed, able 
by their weight to penetrate even into 
the alveoli when inhaled. The drug is, 
according to Dr. Passerini, always well 
borne even in cases of advanced phthisis. 
Under 'its influence the sputa diminish in 
quantity and lose their purulent char- 
acter ; the bacilli become less numerous, 
sleep and appetite are restored, and body 
weight increases, A complete cure is 
reported in five cases after one or two 
months' use of the drug, symptoms being 
undiscoverable even five months after 
leaving off all treatment. We think we 
remember the same claim being made for 
other drugs, all of which have, however, 
after a brief reputation, fallen into the 
limbo of neglect. — Brii. Med. Jour. 



THE TECHNIQUE OF MASSAGE. 

The forms of disease to which Zablu- 
dowski directs attention with reference to 
the use of massage, are : 

1. Traumatic neurosis, with scars from 
the original injury, productive of nerve 
disturbances, that is to say, cases in which 
an individual changed b}^ disease, reacts 
in an abnormal fashion to the bodil}^ ail- 
ment. 

2. Affections of the peripheral nerves ; 
(neuritis and perineuritis) especially of 
traumatic origin. 

3. Nervous dyspepsia with constipa- 
tion, increased formation of gas and ten- 
derness of the abdomen, caused by dis- 
placement and pressure upon the intes- 
tines, with or without a floating kidney. 

In cases of traumatic neuroses in which 
the simple touching the scar produces a 
severe pain. Z. recommends leaving the 
injured spot entirely alone at first. 

One should begin the mechanical man- 
ipulation as far as possible from the scar 



and should work gradually from the cen- 
tre toward the periphery. At each treat- 
ment gradually approach the neurotic 
field, and thus, in three or four treatments 
it will be possible to directly seize the 
scar without producing any irritation, 
which tends to the development of cramp 
or similar effect. In cases in which mas- 
sage works very promptly, the result is 
to be explained by psychical influence. In 
diseases of the peripheral nerves (neuritis 
and perineuritis, paralyses of single 
nerves and muscles) which occur espe- 
cially in the extremities, it is desirable to 
effect the reserptive processes, and to es- 
tablish a "dynamic effect." Z. recom- 
mends here a method which enables us to 
influence the deeper structures without 
much irritation. This is intermittent pres- 
sure which is exercised by the hand of 
the masseur making centripetal rolling 
motions. 

In conclusion Z. describes a method 
which he applies for constipation due to 
atony of the bowel, whether it be with 
general nervous phenomena, or with 
severe pain and distention of the abdo- 
men, high fever and giddiness. Inasmuch 
as we have to do with a local mechanical 
obstruction to the movement of the intes- 
tinal contents, a mechanical treatment is 
naturally the one which first attracts at- 
tention. Z. conducts massage according 
to a method of his own, which requires 
the knee-elbow position. — Review in 
Schmidf s Jahrbucher^ p. jo. 



TREATMENT OF RINGWORM. 
Kerley (TV. V. Med. Journ., October 
loth) advocates the following methods of 
treatment : Two grains of bichloride of 
mercury dissolved in a small quantity of 
alcohol are added to one ounce of equal 
parts of kerosene and olive oil. This 
should be thoroughly rubbed into the 
diseased areas, and the whole scalp thor- 
oughly saturated once a day, until a 
smart inflammation is produced ; the part 
should then be covered with a simple 
ointment until the inflammation has sub- 
sided, when the treatment may be re- 
sumed, but the applications may be made 
less frequent and in a less vigorous man- 
ner. A variation in the treatment, which 
he sometimes found useful, was to rub 
into the diseased areas on alternate days 
with the above a saturated solution ot 
iodine in absolute alcohol. In all cases 
the scalp should be frequently washed 
with soap and water. Slight inflamma- 



Periscope. 



Vol. Ixvi 



tion of the scalp was induced in most of 
the cases, and in a considerable number 
a moderately severe squamous condition 
of the scalp followed on the cure. This 
was remedied by the application of a 3- 
per-cent. solution of resorcine frequently. 
This treatment effects a cure in from six 
to nine weeks. 



KNEIPP'S WATER CURE. 
Dr. A. Schleichner {Zeitschrift fur 
Therapie) describes the system of hydro- 
therapeutics practiced by a priest named 
Pfarrer Kneipp in a small Bavarian vil- 
lage, who, like Priessnitz, has created 
quite a furore in Germany and has gained 
numerous adherents. Kneipp' s system 
consists in certain hydro-therapeutic 
measures, the administration of simple 
household remedies, and the regulation 
of the patient's mode of living. To 
strengthen the nervous system, the pa- 
tient is advised to walk on moist grass or 
in a bath-tub filled up to his ankles with 
cold water. The cold pack, consisting of 
several thicknesses of coarse linen, is em- 
ployed in certain cases, the sheet being 
wrapped around the entire body from 
neck to groin or applied to the abdomen 
or back ; it should not remain longer than 
an hour. As regards the use of baths, 
the cold foot-bath should last from one to 
three minutes ; the warm foot-bath has a 
temperature of 99° F. , and lasts from ten 
to fifteen minutes and is followed by a 
cold bath of half a minute's duration. A 
"half-bath" is administered by letting 
the patient stand, kneel or sit in water 
while the back and chest are washed ; it 
should not last longer than three minutes. 
The sitz-bath is taken before going to 
bed ; its duration may vary from one-half 
minute to three minutes. If taken warm, 
it may last for half an hour, and an infu- 
sion of herbs is usually added to the 
water. The full bath, according to 
Kneipp, is the more effective the shorter 
its duration, and is mainly indicated in 
febrile conditions. The warm full bath 
has a temperature of 90° to 99° F., and 
consists of an infusion of pine-needles. 
It is followed by cold affusion or washing 
of the body with cold water. Steam- 
baths are carried out in a primitive man- 
ner, the steam being supplied by a kettle 
of boiling water. The cold affusion is 
made with a sprinkling-can from which 
the sprinkler has been removed ; the 
entire body, or simply the affected parts, 
may be acted upon ; in weak persons the 



water should be tepid. Another favorite 
manner of applying water is to sponge 
the body or affected parts with a wet 
coarse towel. This procedure is best 
done in the morning and should not last 
more than two minutes. 

Kneipp advises that the patient should 
drink whenever thirsty, but never large 
quantities of fluid at a time, and none 
during the meal. His materia medica 
consists of simple domestic remedies. As 
regards the dietary, he is opposed to ex- 
cessive use of meats ; does not interdict 
beer or wine in persons accustomed to 
their use, but thinks less favorably of 
coffee and tea. He urges an abundance 
of fresh air and exercise, and advocates 
coarse linen underwear in place of woolen 
garments. 



TABULATED TREATMENT OF SYPHILIS. 

Dr. Bontemps, in a paper read before 
the Societe de Medecine d' Angers, gives 
the following table for the systematic 
intermittent treatment of syphilis : 



Months- 


-1st 


2d 




4th 


5th 


6th 


7th 


8 th 


9th 


10th nth 


12tl 


Tears. 


























1st 


M 


M 


£ 


M 


R 


M 


R 


M 


I 


R 


M 


I 


2d 


R 


R 


I 


M 




R 


R 


I 


M 


I 


I 


R 


3(1 




M 
R 


I 


I 




R 


I 


I 


{I 


R 


M 


I 


4tli 


..A 


S 


I 


I 


R 


{? 


I 


I 


R 




I 


I 



M — Mercurials; I — Iodides; R — Rest; S — :*ulphur. 



This table is based upon the methods 
of Fournier and of Martineau. Taken 
altogether, we find that there are ten 
months of mercurial treatment ; twenty 
of iodide treatment ; six of sulphur treat- 
ment, and eight months of rest. To my 
mind there seems to be too much time 
devoted to the iodides ; a certain portion 
could be profitably devoted to the exhibi- 
tion of the mixed treatment, and probably 
with benefit to the patient. Another 
point is the long periods of rest at the in- 
ception of treatment. I have found that 
the same amount of rest, divided into 
shorter periods, with correspondingly 
shorter periods of treatment included, is 
productive of better results and reduces 
to a minimum the tendency to extensive 
or destructive lesions. 



ICHTHYOL IN PYROSIS. 

Dr. Thbr i^Norsk Magazin for LcBge- 
videnskaben, No. 5, 1891) has found ich- 
thyol of use in pyrosis, the sour eructa- 
tions disappearing after one to two one- 
centigramme (one-fifth grain) pills or 
capsules. No disagreeable side- or after- 
effects. 



January 23, 1892. Periscope, 



147 



TREATMENT OF ESSENTIAIv PAROXYS- 
MAI, TACHYCARDIA. 

Dr. Huchard (^Rivista Clinica e Tera- 
peutica, No. 14, 1 891), recommends physi- 
cal and moral rest, lying upon the left 
side or the back, with the head low, slight 
compression of the right or left carotid. 
The chloride of methyl spray, vesica- 
tories or the cautery may be applied to 
the back of the neck. During the attacks 
digitalis bv the rectum, on account of the 
gastric intolerance, will be of service. 
Injections of caffeine or ether are useful 
in the cardiac weakness. Nitrite of amyl 
and trinitrine are contraindicated. Dur- 
ing the intervals the patient should ab- 
stain from coffee, tea, liquors, exciting 
substances and tobacco. The general 
treatment is physical and moral rest, and 
the use of arsenic as a nervine. In tachy- 
cardia, with arterial hypotension, the 
writer advises the sulphate of quinine 
with ergot in the following formula : 

RQuinise sulph. ^ 
Extr. aquos. secal > 

cornut., I aa gm. 4. (Sj). 

Extr. QUO. vomic. cgm. 10. (grs. jss). 
SuflBclent for forty pills. 
Two pills two or three times daily for fifteen to thirty days. 

As a prophylactic, the writer recom- 
mends digitalin, taken morning and even- 
ing for three weeks, fifteen drops of a 
solution I : looo of crystallized digitalin. 



TYPHOID FEVER TREATED BY YEAST. 

Dr. M. B. Thomson, in a recent number 
of an Australian contemporary, records 
some notes of the treatment of cases of 
typhoid by yeast. In all thirty-seven 
cases were so treated. Ten were severe, 
the temperature reaching or exceeding 
104° ; eight moderately severe, tempera- 
ture reaching or exceeding 103° ; eleven 
were mild, although the temperature 
reached 103° ; eight were very mild, the 
temperature never being above 102°. In 
all recovery took place without any 
relapse. This point is worthy of note, 
inasmuch as, according to Fagge, the 
average proportion of relapses is from two 
to eleven per cent. — Med. Press. 



A VEHICLE FOR BISMUTH. 

Dr. Taurence {Gazzetta degli Ospitali, 
No. 24, 1 891), has experimented with 
various substances in order to find the 
best vehicle to keep bismuth in solution, 
and finds glycerine to best fill the require- 
ments. Four parts of glycerine to one of 
bismuth may be employed. 



MEDICINE. 

SYSTEMATIZED DELUSIONS OF AMBI- 
TION WITH HALLUCINATIONS AND 
IDEAS OF PERSECUTION IN A 
CASE OF MENTAL DE- 
GENERATION. 

M. Magnan, in a recent clinic, showed 
the following case : 

K., native of Holland, received a good 
education ; had typhoid fever in child- 
hood. At the age of 18, entered a mili- 
tary school ; there submitted twice to be 
examined to pass for an officer. At the 
age of 27, married a woman who brought 
him 40,000 florins. Nothing especially 
occurred until 1883. The king's son had 
been dead for some years. The second 
son also died and there was no one to 
inherit the throne of Holland. At this 
time he had some doubts as to his birth 
and origin, and gradually convinced him- 
self that he was the son of the king. He 
made a retrospective examination of his 
whole life, bringing up all incidents 
which would serve to strengthen his de- 
lusion. At this time he began to fear 
persecution. 

In 1883, while singing in church, he 
was suddenly apprised of the illness ot 
his son and upon arrival home found him 
dead. He was persuaded that his son 
had been poisoned. He made an exami- 
nation and filed a complaint, notwith- 
standing that' the doctor who attended 
his son stated^ that he died a natural 
death. He thought the governess ought 
to be imprisoned ten years. His conduct 
now became exaggerated. He bought a 
fine house in the country, began to bet 
extensively in lotteries and soon failed. 
His wife and children left him alone with 
the two gardeners. One night he heard 
the dogs bark and said he would go and 
see what was the cause. It was the son 
of the burgomaster, who he said had 
come to assassinate him. At another 
time he took purgative pills, had violent 
colic and said he had been poisoned. 
Often he would overhear conversation in 
the streets of the Hague : ' ' Here is the 
son of the king." He addressed the 
king a note asking for an interview and 
went to Paris during the arrangement of 
his affairs. Each month he offered one 
hundred francs to the consul of Holland 
to prove how much he hated to be 
banished. These, with other delusions 
and hallucinations, characterized this 
case. 



148 



PeriscopL 



Vol. Ixvi- 



THE VAIvUE OF THE PHYSICAL SIGNS 
AT THE APICES OF THE LUNGS IN 

SUPPOSED INCIPIENT PHTHISIS. 
It is a fact well known to physicians 
generally that in health the percussion 
note at the apex of the right lung may 
occasionally be of higher pitch than that 
of the left apex. An examination of one 
hundred healthy symmetrical chests by 
Drs. Fussell and Adams, on the other 
hand, shows that, — 

1. A normal condition at the right 
apex may be considered a diseased con- 
dition. 

2. A diseased condition at the right 
apex may be considered normal. 

3. The normal disparity in favor of the 
right apex ma}^ mask diseased conditions 
at the left apex. 

In the University Medical Magazine for 
June, 1 89 1, these authors publish a tabu- 
lated list of one hundred cases, taken as 
they presented themselves at the dispen- 
sary of the University of Pennsylvania, 
the diseases for which these cases were 
under treatment having no influence on 
the condition of the lungs. 

When it is taken into consideration 
that the usual site of tubercular infiltra- 
tion is at the apex of the lung, and that 
among the first signs of consolidation of 
the lung are higher-pitched percussion 
note, increased tactile fremitus and vocal 
resonance, the importance of the deter- 
mination of the value of these signs is at 
once apparent. Of course there are other 
signs of incipient phthisis ; one of which, 
prolonged expiratory effort, is very sus- 
picious of approaching consolidation, and 
is a phenomenon which is seldom mis- 
leading. It is in those cases where these 
other signs are absent, masked, or very 
slight that these variations spring into 
greater prominence. Again, undoubtedly, 
the higher-pitched note, when existing 
normally at the right apex, is perfectly 
resonant ; it lacks the deadened quality 
noticed in commencing consolidation. 
Yet this difference in quality is hardest 
to distinguish in just those cases where 
the greatest doubt exists, so that practi- 
ally this difference is of no use. It is of 
the utmost importance that signs which 
are perfectly normal should not be mis- 
taken for those of diseased conditions. 
On the other hand, it is equally import- 
ant that we do not overlook diseased con- 
ditions at either apex, considering the 
signs as those of health. In the incipient 
stage of phthisis, so vital is the diagnosis 



for the future of the patient, and so slight 
are the symptoms and signs, that everj^ 
straw adds weight to the conception of 
the case. A positive diagnosis is de- 
manded by patient and as eagerly sought 
by physician. The disease is presented 
in its incipient stage oftener to the prac- 
titioner than any other disease, as its 
symptoms and results are so well known 
to the laity. Hence, in the majority of 
normal lungs, we have conditions which 
at once add suspicion to our conception 
of cases in which incipient phthisis is 
feared. 

In examining this table, consisting of 
the reports of the condition of fifty-eight 
men and forty- two women, we find that 
eleven, or eleven per cent. , have the same 
percussion note at both apices ; nineteen,, 
or nineteen per cent. , have slightly higher- 
pitched note at the right apex ; and sixty- 
nine, or sixty-nine per cent., have 
markedly higher-pitched note at the 
right apex, while one was higher pitched 
at the left apex. In the ninety -two cases 
where vocal resonance was taken, ten 
showed no difference at the apices ; four- 
teen showed slight increase at the right 
apex, and sixty-eight marked increase. 
In ninety-three cases where the tactile 
fremitus was taken, no difference was 
found in eleven cases, slight increase on 
the right side in twenty, while sixty 
showed marked difference. Two cases 
exhibited marked increase of fremitus at 
the left apex. 

In pursuing the examination, as far as 
possible, the results were obtained separ- 
ately by each observer, compared, and 
then obtained together. Many cases 
where slight variation occurred were 
verified in this manner. One observer 
percussed the chest, while the other lis- 
tened in, such a position as to be unable 
to tell which apex was being percussed. 
Any case in which there was any differ- 
ence of opinion as to the existence of au}^ 
variation was put down in the list as 
equal on both sides. All the ordinary 
rules of percussion and auscultation were 
observed. There was no desire to force 
cases into one class or the other ; the 
attitude was simply to endeavor to find 
the exact truth on the subject. 

Supposing a case to present itself with 
higher-pitched percussion note, increased 
tactile fremitus, and vocal resonance at 
the right apex, the question, of course, 
arises whether this is a diseased condition. 
One of three errors may be made, — 



January 23, 1892. 



Periscope. 



149 



1. A normal condition at the right 
apex may be considered a diseased con- 
dition. ■ 

2. A diseased condition at the right 
apex may be considered normal. 

3. The normal disparity in favor of the 
right apex may mask diseased conditions 
at the left apex. 

It is accepted by physical diagnosti- 
cians that the larger size of the right 
bronchus accounts for the increase of 
vocal resonance and tactile fremitus, both 
being due to the same cause, — increased 
transmission of the voice-sounds. As to 
the reason of the higher-pitched percus- 
sion note at the right apex, there is less 
clear and united opinion. The note at 
the left apex ought, if anything, to be 
the higher pitched ; the explanations of 
the contrary conditions existing are not 
satisfactory. One explanation is that the 
liver at the base of the right lung deadens 
the wave-sounds from the tissue above, 
Tv^hile the hollow viscus, the stomach, 
ser\^es more as a sounding-board for the 
left lung. The degree of tension of the 
thoracic parietes and of the lung-tissue 
itself ma}' account for it, as the greater 
the tension the higher the pitch. 

In conclusion, the authors affirm — 

That higher-pitched percussion note, 
increased vocal resonance, and tactile fre- 
mitus are normal at the apex of the right 
lung as compared with the left ; that this 
normal condition can occur in such a 
number of cases and to such a degree as 
to cause in man}" instances a diagnosis of 
consolidation at the right apex ; that 
finally, in deciding doubtful cases ^ other 
signs besides these three are necessary to 
formulate a diagnosis ; continued obser- 
v^ation of cases, where other signs are 
lacking, being necessary to watch the 
possible development of actual disease. 

The authors report in detail three cases, 
which illustrate the existence of these 
three possibilities of error. — Therapeutic 
Gazette. 



STERILIZATION OF MKTAIv INSTRU- 
MENTS. 

Immersion of instruments in antiseptic 
solutions, particularly the two per cent, 
carbolic, is not sufficient to thoroughly 
sterilize them. Thorough mechanical 
cleansing is the first thing to do. After 
use, the instruments are rinsed in com- 
mon water and laid in a hot soda and 
soap solution, and with a brush carefully 
scrubbed. They are then washed again 



and polished with so-called putz stein " 
and alcohol and rubbed with chamois, 
and once more washed off with the soda 
solution and carefully dried. To sterilize 
them the use of dry heat requires too 
high a temperature and too long time. 
Boiling in soda solution is much better. 
The apparatus of Schimmelbusch, as 
made by Lautenschlager, is used. From 
a small box a spoonful (10 cu. cent.) ol 
soda is taken and put in a litre of water 
for use in the sterilizer. Hanging with 
the box are a litre measure, hour-glass 
and match-safe. The instruments are 
allowed to boil from five to fifteen min- 
utes, according to their size. The wire 
tray containing the instruments is then 
removed and placed in a pan containing 
a solution of one per cent, each of soda 
and carbolic acid. 



CHANGES IN THE KIDNEY IN PHTHISIS. 

The condition of the kidneys in phthisis 
has never been fully investigated. Several 
obser\xrs have described a fibroid condi- 
tion. Becquerel and Rayher concluded 
that Bright' s disease was very frequently 
associated with tubercular disease of the 
lungs. Peacock, in one hundred and 
seventeen cases of kidney-disease, found 
30.7 per cent, of phthisis. Frerichs 
found that out of forty-two cases of 
Bright' s disease six also suffered from 
phthisis. Bamberger stated that the 
disease was found in fifteen per cent, of 
those suffering from kidney-disease. In 
the Centi^alblatt fur Allgemeine Pathologie 
and Pathologische Anatomie, February i, 
1 89 1, Dr. C. von Kahlden publishes his 
results on the same subject. He is of 
opinion that slight degeneration of the 
renal epithelium is almost always found 
in active phthisis. It may, however, be 
so slightly marked that it is only visible 
on microscopic examination, and even 
then ma}^ be easily overlooked. The 
kidney may be either normal in size or 
somewhat enlarged. Microscopically the 
following conditions are noticed : The 
surface of the organ is smooth and yellow- 
ish in color ; the capsule peels easily ; the 
cortex is usuall}^ slightly thickened, and 
also 5'ellow in color ; the medullary por- 
tion is pale. The microscopic changes 
chiefly affect the cortex, the parenchyma 
being first attacked. The epithelial cells 
undergo fatt}' degeneration, but are occa- 
sionall}' replaced b}^ fresh epithelial cells. 
The interstitial changes are, therefore, 
secondarv^ and generally slight, and take 



Periscopi 



Vol. Ixvr 



the form of a small round- celled infiltra- 
tion, and some increase of the connective 
tissue. The glomeruli also take part in 
the degeneration. The cortex is not uni- 
formly affected, but the changes take 
place in patches. These lesions are evi- 
dently chronic, as is shown by the thick- 
ened capsule, the atrophy of some of the 
glomeruli, and the changes in shape of 
the epithelial cells of the tubules, these 
being altered from a club form to a cubi- 
cal or cylindrical shape. Clinical symp- 
toms which accompany the renal degener- 
ation are unreliable. Albumen m the 
urine is rarely present. The author 
states that the condition is one of a 
chronic parenchymatous nephritis, and 
thinks that it may be caused by the 
poisonous products of the tubercle bacilli. 
—Layicet. 

THB CELLS OF THE SPLEEN AND 
HEMOGLOBIN. 

Dr. Nicolai Hohlein publishes in his 
inaugural dissertation at the University 
of Dorpat a series of experiments made 
in continuation of the researches of Aug. 
Schwartz and Nicolai Hoffmann at the 
Physiological Institute of Dorpat. The 
former had shown that the protoplasm of 
various cells both destroys haemoglobin 
and regenerates it, and Nicolai Hoffmann 
found in a haemoglobin solution, which 
had been decolorized by spleen cells, an 
albuminoid ; while the same solution, 
treated with hepatic cells, gave no al- 
buminoid reaction. The author chose 
spleen cells, mixing them with three 
times their volume of diluted haemoglo- 
bin solution. Decolorization took place 
on the average after twelve hours, and 
the color was completely recovered in 
from sixt}^ to seventy hours. The author 
was then able to confirm the following 
conclusions Schwartz had arrived at. To 
regenerate a molecule of haemoglobin, it 
is necessary to bring it into contact both 
with the cells and the decolorized liquor. 
Regeneration occurs also when the de- 
colorized liquor is brought into contact 
with fresh spleen cells, but in this case 
the coloring is not so vivid as when the 
same cells are used which caused the de- 
colorization. If the solution which has 
been decolorized by spleen cells is brought 
into contact with liver cells, all power of 
recoloring by the former is completely 
and irretrievably lost. The molecule of 
haemoglobin is mechanically taken up by 
the cell which decomposes it, and during 



the period of complete decolorization of" 
the liquor within the cell it is regenerated. 
The author adds to these the following 
independent results of his experiments.. 
In decolorization, as well as in the process 
of regaining color, the quantity of the 
haemoglobin solution is of less import- 
ance than its concentration, as with a. 
certain medium degree of the latter alL 
effects of the spleen cells cease. Regene- 
rated haemoglobin is distinguished from, 
the original by being decomposed with 
greater facilitj^ by acetic acid, by its bright- 
color and energetic oxidation. The al- 
buminoid in the liquor which has been 
decolorized by spleen cells is cytoglobin. 
During the stage of decolorization, as- 
well as that of regaining the color, a con- 
tinuous new formation of cytoglobin is 
observed. This new formation of cyto- 
globin also takes place when the spleen 
cells are mixed with a 0.6 per cent, solu- 
tion of chloride of sodium, but is in this 
case not so marked as when a solution of 
haemoglobin is used. The haemoglobin 
solution loses and the cells gain iron dur- 
ing the decolorization of the former ; the 
reverse process takes place when the solu- 
tion regains its color. — Lancet. 



RELATION BETWEEN ALBUMINURIA 

AND THE RENAL CIRCULATION. 
Dr. V. Casaretti, of Pisa {Rivista Gen- 
erale Italia7ia di Cli7iica Medica^ August 20, 
1 891), describes some curious results ob- 
served by him in cases of cj^clical albumin- 
uria. The experiments described were 
based on a previous observation of Dr. 
Landi, who had found that in a case of 
this affection he could for a time arrest the 
albuminuria by causing slight disturb- 
ance of the renal circulation by means of 
bandages applied to the limbs. The 
present observations were made on two 
cases of cyclical albuminuria, and on a 
third which presented the clinical signs 
of nephritis with swelling of the face, 
etc., but without other renal history. In 
the last case albuminuria was constantly 
present, but in the two first it was absent 
in the early morning, only ver>" slight 
after the first meal, and pronounced after 
dinner. Application of ' ' expulsive band- 
ages ' ' to the limbs had a most remark- 
able influence on these phenomena, the 
albumen disappearing entirely from the 
urine while the bandages were kept ap- 
plied in the cases of cyclical albuminuria, 
and being very considerably diminished 
in the more serious case. Not only this, 



{anuary 23, 1892. 



Periscope. 



but the effect was observable within a 
very short time after their application. 
The excretion of urea also was markedly 
diminished. As the author remarks, the 
alteration of the renal tissue must be 
very slight in these conditions if such a 
trivial alteration of the renal circulation 
can so rapidly modify or abolish the 
symptoms. The method may, if further 
observation should establish the above 
results, prove a useful one both in di- 
agnosis and treatment. — Brit. Med. Jour. 



PAIN IN HEART DISEASE: CON- 
CLUSIONS FROM THE STUDY 
OF 483 CASES. 

Nothnagel {Zeitschrift fur klinische 
Median, Vol. XIX. No. 3) tabulates 483 
cases of valvular disease of the heart 
with reference to pain. Lesions at the 
aortic orifice were most frequently accom- 
panied with pain, while lesions at the 
mitral orifice were the least affected. Six- 
ty per cent, of the cases of regurgitation 
were accompanied by pain, while only 
seven and one-half per cent, of the cases 
of mitral regurgitation had painful attacks. 
Curiously enough the combination of mi- 
tral regurgitation with aortic regurgitation 
seems to reduce the percentage of painful 
cases, only eighteen per cent, of such 
cases having painful attacks. He calls 
attention also to the frequency of pain in 
cases of disease of the heart-muscle with- 
out valvular disease. He holds that in a 
case where the diagnosis is uncertain, the 
occurrence of pain in the cardiac region, 
while, of course, not making the diag- 
nosis sure, is of the greatest moment in 
pointing toward heart disease. Cases of 
arterial sclerosis, with cardiac hypertro- 
phy, are much more frequently accom- 
panied by pain than other forms of this 
latter class. — Univ. Med. Mag. 



SURGERY 



RESULTS OF TREATMENT OF REDUC- 
IBLE HERNIA BY ALCOHOLIC 
INJECTIONS. 



The original modus operandi of 
Schwalbe, says Dr. Theodore Zangger 
in the Lancet, who introduced this form 
of treatment in 1871, is slightly modified 
by Dr. Steffen, of Regensdorf (Zurich). A 
70 per cent, solution of alcohol was used, 
and from two to four grammes of this 
fluid were injected round the saccus her- 
niosus (hernial sac) after reposition of the 



hernia. The treatment was ambulatory ; 
first one or two injections a week were 
made, then at greater intervals. Before 
being dismissed from medical supervision 
the patient had to go without the truss 
which he used during the treatment. 
The time of treatment varied from one 
month to two years and a half or more. 
In 293 cases there were 83 (62 per cent.) 
cures, 6 (48 per cent.) improvements, 9 
(9 per cent.) of negative results. A cure 
was considered to have been obtained 
when, at least one year after dismissal of 
the patient, the hernia was neither to be 
seen nor felt during coughing or under 
intra-abdominal pressure, and when the 
patients, most of whom belonged to the 
laboring class, had been at their usual 
work for six or seven months. In 10 per 
cent, of the cases dismissed as cured the 
hernia returned, owing to various causes. 
The age of the hernia isit venia verbo) was 
not without influence as to the result 
obtained, as will be seen from the follow- 



ng list : — 








Duration of 


No of 


No. of 


Per- 


disease. 


cases. 


cures. 


centage. 


Hernia incipiens . . 


, . n 


11 


100 


Date, a few dajs . . 


. 10 


10 


100 


Under ^ year . . . 


. 44 


41 


93.2 


i " . 


. 45 


41 


91 


10 " . ". . 


, . 120 


101 


84.2 


" 30 " . . . 


. 52 


34 


65.4 


Over 30 " . . . 


, . 5 


4 


80 


Date unknown . . 


6 


3 


50 



Dr. Steffen comes to the following con- 
clusions : About four-fifths of small and 
medium-sized reducible herniae can be 
cured, the wearing of a truss becoming 
in most cases superfluous. The prognosis 
improves the younger the individual, and 
the shorter the time the hernia has existed. 
Incipient cases should, therefore, be 
treated by injections, and not left to the 
chance of a spontaneous cure under a 
truss. Ambulatory treatment, with pauses 
of from four to seven days, gives better 
results than daily injection whilst keep- 
ing the patient in bed. In most cases the 
patient does better to continue his usual 
occupation, wearing a truss during the 
time of treatment. This method is also 
adapted to herniae which cannot be re- 
tained by a truss, the latter being able 
to be worn, and keeping back the hernia 
after a course of treatment. In a few 
cases only toxic effects (alcoholism, 
urticaria, vertigo) were observed. This 
method of treatment is not entirely with- 
out danger ; but accidents will be rare if 
due care is taken and regard paid to the 
anatomy of the respective parts. 



Periscopi 



Vol. Ixvi 



CAMPHORATED NAPHTHOL IN SURGI- 
CAL TUBBRCUIvOSIS. 

Jules Reboul (^Centralblatt f. Chirurg.) 
brings forward a new antiseptic made by 
incorporating loo parts of beta-naphthol 
with 200 parts of finely powdered cam- 
phor, and then carefully heating until 
complete melting occurs, for the treatment 
of tuberculosis of those parts accessible 
to surgical treatment. This camphorated 
naphthol is an oily fluid, insoluble in 
water, but miscible with alcohol, fats, 
ether and chloroform. It is decomposed 
by exposure to the air, the camphor 
evaporating and the naphthol becoming 
crystallized. lyight decolorizes it, but it 
may be preserved in dark, well-stoppered 
bottles. It is not a true chemical com- 
bination, but is probably only a molecu- 
lar union. The antiseptic qualities of the 
new antiseptic depend, to a great extent, 
upon those of the beta-naphthol. Its 
antiseptic qualities have been proven by 
means of culture, as well as by clinical 
experiments, by R. It has been used 
with good results as an irrigating fluid in 
joints, bony cavities, tendinous sheaths, 
cold abscesses in the pleural and uterine 
cavities ; and in addition to an interstitial 
injection, by instillation in cases of tuber- 
culosis of the bladder, and in the prepara- 
tion of dressings and disinfection of in- 
struments. No poisonous symptoms have 
been observed, although the undiluted 
fluid was employed. 



STERIIvIZING DRESSINGS BY MEANS 
OF STEAM. 

Steam is now almost universally used 
for sterilizing dressings. In regard to 
the use of dressings impregnated with 
antiseptics, it should not be forgotten 
that dryness is a greater hindrance to the 
growth of germs than are antiseptics, and 
that it is better to use absorbent aseptic 
material than non-absorbent antisepti- 
cally-prepared stuff that allows stagna- 
tion of the wound discharges. It is very 
doubtful whether material which has been 
through the many processes necessary 
for its antiseptic impregnation is as free 
from germs as is that sterilized by steam. 
The toxic action of the antiseptic also 
makes its use undesirable. In using a 
steam sterilizing apparatus it is better to 
have the steam enter at the top and 
escape below ; it is quicker and more 
eflicacious. lyautenschlager' s apparatus 
is used by Von Bergmann. This is com- 



posed of an outer asbestos jacket and two 
inner copper cylinders, between which 
the water is held. When the lid is on, 
the steam ascends between the two inner 
cylinders and passes inside to the dress- 
ings from openings in the top ; it escapes 
from an opening near the bottom. Heat 
is applied by a gas jet beneath the appa- 
ratus, and it goes up along the sides 
between the outer copper cylinder and 
the asbestos jacket to escape by holes at 
the top. The dressing is allowed to re- 
main three-quarters of an hour, subjected 
to a heat of 100° C. In order to avoid 
handling and exposure, the dressings are 
placed in tin kettles or boxes, having 
openings at the top and bottom which 
can be closed by means of a slide. The 
openings are left uncovered and the appa- 
ratus and dressings placed in the steri- 
lizer. When sterilized, the slides are 
shut and the box taken to the operating 
clinic for use. 



AMPUTATION OF THE LEG UNDER 
COCAINE ANESTHESIA. 

Dr. R. H. Cowen writes in the Infernal, 
Jour. Surgery that having seen no recent 
report of major amputation in which 
cocaine hydrochlorate has been used, he 
presumes that surgeons generally are 
slow in following Coming's method. 
The following case is his own : 

Artie McPhail, a negro track-hand, 
was knocked from a trestle forty -five feet 
high, sustaining a fracture of the lower 
portion of the tibia and the metatarsal 
bones. When he came under his care, 
ten days later, he found him with an 
enormously swollen ankle, and a large 
suppurating wound opening into the 
neighborhood of the j oint. Being unable, 
on account of the tremendous amount of 
swelling,, to decide the exact nature of 
the injury, and leaning to conservative 
surgery, he tried faithfully antiseptic 
irrigation and drainage. Finding, how- 
ever, no improvement, an exploratory 
incision was made under cocaine, reveal- 
ing complete comminution of the tarsal 
bones. 

He now resolved on amputation. The 
negro was very much afraid of chloro- 
form, and positively refused to take it. 
He decided to use cocaine. After apply- 
ing the rubber bandage above the site 
selected for amputation, he injected the 
cocaine as advised by Wyeth, carrying 
the needle just under the skin, elevating 
its point, and injecting as the needle was 



January 23, 1892. 



Periscope, 



153 



withdrawn. This was done in four 
places, by which means anaesthesia was 
rendered complete all around the limb. 
He now proceeded to dissect the flaps. 
Then one or two punctures were made 
into the muscular tissue, around the 
limb, penetrating the periosteum, the 
fluid being ejected as he withdrew the 
needle. The operation was then com- 
pleted. At no stage of the procedure 
was there the slightest pain. The patient, 
who was afraid of a pin scratch and was 
badly frightened beforehand was per- 
fectly satisfied with the result and much 
astonished " that it did not hurt him." 

There were no bad symptoms either 
during or after the operation. On the 
fifteenth day after, he removed the dress- 
ing for the first time. Union had taken 
place by first intention, with the excep- 
tion of a small spot left for drainage, 
which was not as large as one's little 
finger nail. 

RESECTION OF THE SPINE FOR SPON- 
DYI.ITIC PARALYSIS. 

Kraske {Langenbeck' s Archiv., Bd. 41, 
S. 831) discusses this subject at length. 
He had occasion to perform this opera- 
tion several times, but the results were 
not so successful as one would be led to 
expect from Macewen' s article. Paralysis 
from pressure is the kind most apt to be 
benefited by operation, but is usually 
better treated by extension. In tuber- 
culous disease, abscesses and granulation, 
tissue may form around the cord, consti- 
tuting a pachymeningitis. The exudate 
may compress the cord and make it 
anaemic. Interference with the lymph 
and blood streams also occurs and may 
cause oedema. Circulatory disturbances 
can exist for a long time without causing 
an irreparable paralysis. When, as is 
rarely the case, the disease affects the 
arches instead of the bodies of the ver- 
tebrae, operation is indicated and will 
probably be followed by good results, 
The improvement which sometimes oc- 
curs in these cases without operation has 
been, in his experience, only temporary. 
This has made him more willing to resort 
to operative procedures. The first case 
operated on had disease of the arches. 
The results were brilliant. Sensation 
began to return the same day and in two 
days was normal. On the fourth day 
motion began returning, and in four 
weeks the patient began to walk. Two 
months later the paralysis returned, and 



the patient died of tuberculosis of the 
lungs seven months after. In a second 
case an exudate into the canal was found, 
but no good results came from the operation 
and the patient died eight weeks later. 
In two other cases granulation masses 
were found overlying the dura ; in one of 
these recovery was almost complete in two 
months ; he then relapsed and is now 
dying of tuberculosis of the lungs. The 
results in the other case were not so 
rapid, but were marked for a while and 
then remained stationary. Operation 
may be advised also in those cases of 
kyphosis in which treatment has proved 
useless, and in which the onset of the 
paralysis was rapid, and involved the 
bladder and rectum. These cases lead 
to a rapid death anyway, and if allowed 
to remain long, the paralysis is irrepar- 
able. — Univ. Med. Mag. 



A N E W OPERATION FOR S PASMODIC WRY- 
NECK, NAMELY, DIVISION OR EXSEC- 
TION OF THE NERVES SUPPLYING 
THE POSTERIOR ROTATOR 
MUSCLES OF THE HEAD. 

W. W. Keen, M. D., has devised and 
performed the following operation in 
view of the implication of the posterior 
muscles of the neck {Annals of Surgery, 
January, 1891) which rotate the head in 
cases of spasmodic torticollis. The opera- 
tion consists of the following steps : 

First Step. — The field of operation 
having been shaved and disinfected, 
make a transverse incision about half an 
inch below the level of the lobule of the 
ear, from the middle line of the neck 
posteriorly, or even slightly overlapping 
the middle. This incision should be two 
and a half to three inches long. 

Second Step. — Divide the trapezius 
transversely. 

Third Step. — Dissect up to the trapezius 
and find the occipitalis major nerve as it 
emerges from the complexus and enters 
the trapezius. In the complexus is an 
intra-muscular aponeurosis. The nerve 
emerges from the complexus at a point 
between this aponeurosis and the middle 
line, usually about a half inch below 
the incision, but sometimes higher up, 
and then enters the trapezius. It is 
alwaj^s a large nerve of the size of a stout 
piece of catgut, and it is easily found if 
sought for at the right place. 

Fourth Step. — Divide the complexus 
transversely at the level of the nerve. 



154 



Periscope, 



Vol. Ixvi 



This division should be made by repeated 
small cuts, so as not to cut the nerve 
which is our guide, after which dissect 
the nerve still further down from the 
anterior surface of the complexus, where 
it arises from the posterior division of 
the second cervical. Cut, or better, 
exsect a portion of the posterior division 
before the occipitalis major arises from it, 
so as to catch the filament to the inferior 
oblique muscle. This divides the second 
cervical. 

Fifth Step. — Recognize the inferior 
oblique muscle by following the sub- 
occipital nerve towards the spine. The 
nerve passes immediately below the 
border of the muscle. 

Sixth Step. — Recognize the sub-occi- 
pital triangle formed by the two oblique 
muscles and the rectus capitis posticus 
major. In this triangle lies the sub-occi- 
pital close to the occiput. It should be 
traced down to the spine itself, and be 
divided, or better, exsected. This divides 
the first cervical. 

Seventh Step. — An inch lower down 
than the occipitalis major, and under the 
complexus, is the external branch of the 
posterior division of the third cervical to 
the splenius. When found it is to be 
divided or exsected close to the bifurca- 
tion of the main trunk. This divides the 
third cervical. 

A drainage-tube and horse hairs are to 
be inserted, and as the patient lies oij 
the back, although the wound is very 
deep, the condition is most favorable for 
good drainage. If desired, the posterior 
muscles can be united by buried sutures, 
independently of those in the skin. The 
after-treatment is the same as for ordinary 
operations. 



OBSTETRICS. 



CESAREAN SECTION FOR A GIANT 
INFANT. 

Rachel and Neumer {Repertoire d' Ob- 
stet. et de Gynec, May 25, 1891) report the 
case of a woman, forty years old, the ab- 
domen of whom, in the twelfth pregnan- 
cy, was enormously distended. The labor 
not progressing, version was attempted, 
but the foetus would not pass the superior 
strait. Disarticulation of the leg, pre- 
paratory to evisceration, was attempted, 
but was unsuccessful. Finally, Caesarean 
section was decided upon. The mother 
died soon after the extraction of the foetus. 



The latter, almost exsanguinated as a re- 
sult of the amputation, weighed twenty- 
two and a half pounds. The parents 
were not unusually large. The only ex- 
planation of the great size of the foetus 
lay in the age of the mother and the num- 
ber of pregnancies and in the fact that 
the fatal pregnane}^ had passed one month 
bej^ond term. — Lyon Medical, July 12, 
1891. 



PERFORATION OF UTERUS BY SOUND, 
AND FATAL SUBLIMATE POISONING. 

Dr. Gebhard {Nouvelles Arch, d Obstet. 
et de Gynec, August, 1891), recently ob- 
serv^ed a patient who had been under 
treatment from November 5th, 1890, for 
gonorrhoea. A i in 5000 sublimate solu- 
tion was thrown up by means of a Boze- 
man's sound, at intervals of a day or two, 
in the out-patient room. On the third 
occasion, November nth, immediately 
after the introduction of the sound, the 
patient complained of pain. After nearly 
a pint of the solution had been thrown 
up, the pain increasing, the injection was 
suspended. Vomiting and faintness came 
on rapidly. Perforation of the uterus 
and entrance of the solution into the 
peritoneal cavity was diagnosed. An 
opium suppository was administered. 
Dysenteric diarrhoea followed in a few 
hours. On the next day complete anuria 
set in. Mucus was continuously dis- 
charged from the rectum, which protruded 
and was ulcerated. Stomatitis with a 
trifling amount of salivation began on the 
third day. The patient died on the eighth 
day. Acetate of potash was given to pro- 
mote diuresis, but completely failed in its 
object ; pilocarpin caused profuse concen- 
trated perspiration, which exhausted the 
patient and irritated her skin. Opium 
had been suspended early in the course 
of the case, Dr. Gebhard believing that it 
was contra-indicated in dysenter>^ At the 
necropsy two complete perforations of the 
fundus uteri were found, lying close 
together near the right tube. The peri- 
toneum was inflamed ; the entire large 
intestine and four inches of the ileum 
were ulcerated and in parts sloughy. One 
ulcer had perforated the sigmoid flexure. 
In the tubuli uriniferi were found creta- 
ceous deposits of the kind described as 
occurring in the kidneys of patients dead 
from mercurial poisoning. Dr. Gebhard 
dwells at length on the pathology of this 
condition. It appears certain that stoma- 



January 23, 1892. 



Periscope, 



155 



titis and salivation, which follow so sharp- 
ly on an overdose of mercury by inunction 
or friction, are not the first symptoms in 
poisoning by mercurial injections used 
after child-birth. In that case diarrhoea 
is the earliest sign, audit rapidly becomes 
mucous, sanious, and ultimately foetid. 
It represents gangrenous dysentery. The 
next symptom is a marked diminution in 
the excretion of urine, often ending in 
suppression. Stomatitis follows third, 
and may be severe, but salivation is not 
constant even in fatal cases. The tem- 
perature is subnormal. In the case above 
related, where there was acute traumatic 
peritonitis at the beginning, the tempera- 
ture was high for a few days, but fell 
below normal when the symptoms of 
poisoning began to predominate. Ery- 
thema is rare. — Brit. Med. Jour. 



URETHRAL CARUNCLK. 

Christopher Martin {Birmingham Medi- 
cal Review, September, 1891) thinks this 
neoplasm has hardly received the atten- 
tion it deserves. He classifies it amongst 
the vascular tumors. It is exceedingly 
doubtful whether the connection between 
the majority of causes usually assigned 
to it and the disease is more than acci- 
dental. On the other hand, he thinks it 
likely that in many cases the exciting 
cause is a highly acid or irritating condi- 
tion of the urine. Uric acid is peculiarly 
responsible for many cases. At the end 
of each act of micturition a drop of highly 
concentrated urine loaded with sharp 
crystals is left at the meatus. The crys- 
tals settle on the mucous membrane, and 
possible lodge in the glandular crypts 
w^hich are so abundant there, and the re- 
peated irritation of their presence deter- 
mines the new growth. This irritation 
is partly mechanical, partly chemical. 
Whether or not it actually causes it, cer- 
tain it is that, after the growth has de- 
veloped, a highly acid urine frightfully 
aggravates the patient's sufferings. The 
great symptom is pain. The suffering is 
out of all proportion to the size of the 
growth. The distress is present on walk- 
ing, passing urine, during coition, or at 
any time the parts may be impinged upon. 
The diagnosis is made complete on in- 
specting the external genitals. On draw- 
ing apart the labia, there is seen at the 
meatus urinarius, or just within it, a 
small bright crimson growth. It varies 
in size frOm a pin's head to a cherry, but 



is generally about the size of a pea. It 
is usually situated on the posterior lip of 
the meatus. It is very soft and friable, 
and bleeds readily on manipulation. If 
carefully prepared sections of a caruncle 
are examined with a moderate power, 
the growth is seen to consist of very 
numerous and widely dilated capillary 
loops embedded in a delicate connective- 
tissue stroma. The treatment consists in 
the copiplete removal of the growth. The 
patient is anaesthetized and placed in the 
lithotomy position. An elliptical incision 
is made in the mucous membrane of the 
vestibule around the meatus, and about 
one-sixth of an inch distant from it. By 
means of fine scissors this incision is 
deepened, and the entire lower end of the 
urethra, for about one-third of an inch of 
its extent, is separated from the surround- 
ing tissues. The piece of the urethral 
canal thus isolated is gently drawn down 
and removed by a snip of the scissors. 
The edge of the divided urethral mucous 
membrane may then be united to the 
edge of the divided vestibular mucous 
membrane by a few sutures, or the raw 
surface may be allowed to granulate. 
Cicatricial stricture may be prevented by 
the regular passage of a soft bougie. If 
a stricture should form, it may be easily 
remedied by slitting the urethra up for 
about a third of an inch. The prognosis 
as to the likelihood of recurrence after 
removal should be guarded. — Univ. Med. 
Mag. 

TETANY IN MENSTRUATION, PREG- 
NANCY AND LACTATION. 

Dr. von Jaksch ( Wien. med. Presse, 
1 89 1, No. 23) noticed the characteristic 
spasms of tetany in a woman, aged thirt}^- 
five, during the fifth month of preg- 
nancy. She first noticed tetany, before 
a menstrual period, when nineteen years 
old. The symptom subsided and did not 
reappear till eighteen months later, dur- 
ing her first pregnancy. The second and 
third pregnancies were free from tetau}^, 
which reappeared during the fourth, and 
also the fifth, when she was under obser- 
vation. This case was essentially chronic 
and seemed to arise from some disturb- 
ance associated with extirpation of strum- 
ous glands, dyspepsia, pregnancy and 
lactation. According to Professor Schauta, 
only a few cases of tetany in direct asso- 
ciation with pregnancy have been recorded. 
Meinert, of Dresden, collected nine such 
cases in 1885. In one of these tetany 



156 



Periscope, 



Vol. Ixvi 



appeared in the third and sixth preg- 
nancies, at an interval of eight years. 
The symptom increased towards the end 
of pregnancy, and ceased after delivery. 
Miiller, of Berne, records a very instruc- 
tive case. A patient, aged fortj^-five, 
suffered from tetany from the age of ten 
upwards, the attacks increasing greatly 
during her only pregnancy. Trousseau 
has seen forty cases of tetany during lac- 
tation, and about as many instances of 
this curious affection have been observed 
during menstruation. — Brit. Med. Jour. 



PROPHYLAXIS OF PUERPERAL FEVER 

J. Veit {^Berlin. Klin. Wochensch., nth 
May, 1 891) contributes an important 
paper on this subject, advocating almost 
complete abstinence from internal exami- 
nation in attendance on labor. The ex- 
ternal examination yields the position of 
the fundus, of the child and of the head, 
the condition of the child, of the mother, 
and of the membranes ; and if these are 
all normal, no internal examination is 
necessary. The indications for internal 
examination in the first period of labor 
are — (i) General disturbances — e. g., 
eclampsia, nephritis, fever, etc. ; (2) Local 
disturbances — e. g., discharge of blood, 
abnormal painfulness of labor or long 
duration ; (3) Departure from the normal 
in external examination — e. g., position 
of head above pelvis in primiparae or 
after escape of waters in multiparse, ab- 
normal distension of lower uterine seg- 
ment, slowing of foetal heart sounds, etc. 
In the second stage of labor internal 
examination is only rarely indicated, and 
really only when the question of operative 
aid arises. In the third stage internal 
examination should only be made when 
there is excessive haemorrhage, and in 
the puerperium onl}^ in fever or haemor- 
rhage. 

AN EARLY SYMPTOM OF WHOOPING- 
COUGH. 

Dr. Huguin, of Tourteron, affirms 
{U7iion Med. du Nord-Est, May, 1891) 
that photophobia with dilatation of the 
pupil is a useful diagnostic symptom of 
whooping-cough in the early stage, be- 
fore the cough has become characteristic. 
Hfe cites three cases in support of this 
opinion ; two of the patients were chil- 
dren and one an adult, and in all of them 
the 'symptoms referred to preceded any 
other manifestation of the disease. — Brit. 
Med. Jour. 



PEDIATRICS. 

BACTERIOLOGICAL RESEARCHES UPON 
THE SALIVA OF CHILDREN SUF- 
FERING FROM MEASLES. 



The investigation of Mer}^ and Pierre 
Boulloche lead them to conclude that the 
pneumococcus and the streptococcus are 
to be found in the saliva of children suf- 
fering with measles, with greater fre- 
quency than in healthy children. 
Broncho-pulmonary accidents rarel}^ ap- 
pear in connection with measles except 
in those cases in which the streptococcus 
or pneumococcus is to be found in the 
saliva. After death one may trace the 
pathogenic microbe which has been found 
in the saliva in the upper air passages as 
far as the smaller bronchi. The very 
frequent presence of the pathogenic 
agents of broncho-pneumonia in the 
saliva of children suffering with measles 
appears to explain the great number of 
broncho-pulmonary complications with 
that disease. Hence the necessity' of the 
most vigorous antisepsis of the buccal 
cavity during the progress of the disease. 



INTUBATION IN 1890-91. 

A 5^ear ago Professor Von Ranke pub- 
lished statistics of 413 cases of intuba- 
tion, collected from German, Austrian, 
and Swiss (German) sources, and com- 
pared them with 866 tracheotomies col- 
lected from the same sources, and 
performed within recent years. He now 
reports {Miinchener medicinische Wochen- 
schrift, October 6, 1891) 365 cases of in- 
tubation performed for diphtheritic croup 
in Germany, Austria, and Switzerland 
during the past year. Of these cases 94 
were his own and the remainder were 
performed by the six following operators, 
namely, Ganghofner, Jakubowski, Von 
Muralt, Unterholzner, Schwalbe, Bagin- 
sky, and Escherich. He has also pre- 
sented for comparison 237 cases of 
tracheotomy performed during the same 
period by Jakubowski, Steffen, and 
Unterholzner. Of the 365 cases of in- 
tubation 348 were performed for primary 
diphtheria, and 17 for diphtheria secondarj^ 
to measles. Of the former 143 recovered, 
or 41 per cent., and of the latter 5 recov- 
ered, or 29.4 per cent. Among the whole 
365 cases, therefore, there was I48 recov- 
eries, or 40.5 per cent. It must be stated, 
however, that tracheotomy was performed 



January 23, 1892. 



Periscope. 



157 



in 83 cases, or in nearly a fourth of the 
whole number, after intubation had been 
tried. Of these 6 eventually recovered, 
and it is not quite accurate to include 
these among the recoveries obtained by 
intubation, as Von Ranke appears to have 
done. Of the 237 cases of tracheotomy 
which he collected, 78 recovered, or 32.8 
per cent. The results of intubation are, 
therefore, superior to tracheotomy, so far 
as these ^statistics are concerned, and 
there is a decided improvement in the 
results of intubation over those shown in 
Von Ranke' s former report. On that 
occasion the recoveries from intubation 
were 34 per cent. , and from tracheotomy 
38.1 percent., so that the relative posi- 
tion of the two operations is now re- 
versed. The author attributes the better 
results to the greater experience which 
operators now possess, and to the im- 
proved tubes which are now employed. 
He attributes his own improved results in 
no small degree to the fact that he now 
leaves the thread in place, and has re- 
course to the extractor for removal of the 
tube onl}' in exceptional cases. He 
thinks it a great advantage that, with the 
thread in place, the nurse is able to re- 
move the tube when there are signs of 
its being blocked, and he has noticed 
that after its removal in such cases more 
or less membrane is often expelled, and 
the breathing is easier for a time. He 
lays stress on the fact that ulceration 
from pressure of the tube is now very 
rarely found, and this he believes to be 
due to the employment of properly con- 
structed tubes. — Brit. Med. Jour. 



HYGIENE. 



THE DIETETIC VALUE OF PEPTONES. 

In the current number of the Joufnal 
de Pharmacie of Antwerp, M. Denaeyer 
describes a very simple method for the 
determination of the dietetic value of pep- 
tones. The complete analysis is tedious 
and difficult, and it is even now b}^ no 
means perfect. M. Denaeyer himself has 
done much towards its improvement, and 
we are not the less grateful to him for 
giving us a method by which the com- 
parative merits of different commercial 
samples can be obtained with simplicity 
and some approximation to accuracy. 
The methocldepends on the fact that the 
more valuabil^ constituents of a peptonic 
fluid are precipitated by strong alcohol. 
To this class belong albumen, albumose. 



peptone, and one variety of gelatine. 
The alcoholic extract retains in solution 
definite compounds such as creatine, 
tyrosine, and urea. The mode of work- 
ing is as follows : 10 cc. of a 20 per cent, 
solution of peptone are treated with 100 
cc. of strong alcohol ; after standing for 
twenty-four hours the extract is removed 
by decantation, and the precipitate and 
extract are separately evaporated to dry- 
ness, the latter at io5°C., and each is 
carried to constant weight. The dietetic 
value of the peptone depends on the 
percentage of the precipitate, which con- 
tains all the true food constituents. M. 
Denaeyer states that the extract should 
not amount to more than 30 per cent, of 
the whole dry matter, any larger propor- 
tion being due to products of metamor- 
phosis — such as leucine, tyrosine, aspartic 
acid, glycocol, amido-butyric acid, and 
the like. Such an assay, although of 
practical utility, cannot supersede com- 
plete analysis. It is evident, for ex- 
ample, that gelatin would be reckoned by 
the above process along with the valuable 
peptone constituents, since strong alcohol 
precipitates this body. — Lancet. 



TO DISTINGUISH MARGARIN FROM 
BUTTER WHEN THE TWO 
ARE MINGLED. 

"Alimentary fats," saj^s M. I^eze, in 
the Repertoire de Pharmacie, * ' usually 
contain from 10 to 12 per cent, of water, 
and, therefore, in searching for a substance 
to free from this element, it is necessary 
to utilize something that has a great 
avidity for the same, without any affinity 
for the fat." 

Syrup of sugar is his choice as an 
agent in this respect. A solution of 
sufficient density renders easy the separa- 
tion of the two substances. He pours 
into a test tube of 10 ccm. capacity i or 
2 ccm. of simple syrup, places the tube in 
a water bath, and adds, little by little, the 
butter to be assayed, until the 10 ccm. 
mark is reached. The tube is then corked 
and shaken, and then a strong thread is 
passed around the mouth and the tube is 
rapidly whirled around the head for 
several seconds. When the whirling 
stops, if the butter is pure, the fatty 
matter is clear and limpid, and the 
whitish emulsion of residual milk, water, 
and syrup is voluminous and well 
marked. If margarin' be present, the 
fatty matter remains turbid and milky. 



158 



Periscope. 



Vol. Ixvi 



This process permits of the detection of 
20, or even 15, per cent, of adulteration. 

The aspect of the melted fats is 
characteristic, and, more than this, 
margarin exhibits normally the phenom- 
enon known as super-fusion, and com- 
municates this property to fats with 
which it is mingled. Thus we see a pure 
butter in cooling becomes first turbid, 
and finally becoming pasty, while butter, 
even with only a small amount of mar- 
garin, always preserves a semi-transpar- 
ent condition. 



MEDICAL CHEMISTRY. 



TO OBTAIN PURE OXYGEN RAPIDLY. 

Zinno's method consists in mixing in- 
timately 200 gm. of powdered potassium 
permanganate with an equal weight of 
barium binoxide. On the addition of 
water, oxygen is disengaged. With the 
amount stated, at ordinary temperature, 
13,620 ccm. of pure oxygen are generated. 
The oxygen is rapidly produced, and is 
not contaminated by chlorine or chlorine 
products. 

BROMOL. 

Bromol, which was introduced into 
therapeutics by Dr. Rademaker, is a 
chemical compound, tribromophenol, and 
is obtained as a white flocculent and 
gradually crystalline sediment when 
bromine water is added to an aqueous 
solution of carbolic acid. Pure tribromo- 
phenol occurs as a white crystalline 
substance which melts at a temperature 
of 203° F., and is nearly insoluble in 
water, but readily so in alcohol, ether, 
chloroform, glycerine, and in fatty and 
ethereal oils ; the odor is disagreeable, 
like that of bromine ; the taste is sweet 
and astringent. According to some ex- 
periments previously published by 
Grimm, the antiseptic virtues of bromol 
would seem to rival those of carbolic acid. 
When it is applied to recent wounds it 
causes a sensation of burning and has a 
caustic action ; it stimulates atonic 
granulations, and produces a favorable 
effect on tuberculous processes. In 
gangrene it acts as a powerful disin- 
fectant, and accelerates the separation of 
dead matter. Dr. Grimm applied it to 
wounds either in a pure state or mixed 
with some indifferent powder, and as an 
ointment. He also employed it to im- 
pregnate bandages. He considered it 
inapplicable to the mucous membrane of 



the mouth, nose, and pharynx, on ac- 
count of its caustic properties. Dr. Rade- 
maker uses bromol either in substance or 
in solution of olive oil of the strength of 
I in 30, or as an ointment of the strength 
of I in 10. In diphtheria he brushes the 
membrane w^ith a glycerine solution of 
the strength of i in 25. As tribromo- 
phenol remains undissolved by the 
gastric juice and is only slowly acted 
upon during its passage through the intes- 
tinal canal. Dr. Grimm made use of it as 
a disinfectant of the bowel, giving it in 
doses of from three to seven and a half 
grains per diem. Dr. Rademaker also 
has adminstered it in cholera infantum 
in doses of from five to fifteen milli- 
grammes, and has prescribed it in typhoid 
fever. It is secreted by the kidneys in 
the form of tribromophenol-sulphonic 
acid. — Lancet. 



ALKALOIDAL ASSAY OF NARCOTIC 
PLANTS. 



Dr. O. Schweissinger has has occasion 
to investigate the alkaloidal yield of 
narcotic plants cultivated near Berlin. 
He reports on his results in Pharni. Cen- 
tralhalle (No. 41). The method of assay 
which he used was the following : 

Ten grammes of finely cut dry herb 
(aconite, belladonna, etc.) are put into a 
flask, digested (warm) over night with 
209 c.c. of water containing i c.c. of di- 
luted sulphuric acid, the mixture being 
occasionally agitated. Flask and con- 
tents having been weighed as soon as 
the latter had been introduced, any loss 
of weight which the apparatus has suf- 
fered during standing is made good by 
adding enough water to restore the 
original weight. The mixture is then 
allowed to cool, strained, the residue 
pressed, and the strained liquid measured. 
It will measure, say, 180 c.c. (which 
would correspond to 9 gm. of herb). 
This amount is now evaporated on 
the water bath under constant stirring, 
during which time the temperature is 
conveniently kept at 65° C. (149° F.). 
When the residue weighs about 20 gm. 
the thin fluid extract is poured 'into a 
measuring cylinder or flask of the 
capacity of 100 c.c, and alcohol then 
added up to the mark (100), which causes 
precipitation. The whole is then thor- 
oughly shaken. (Without this precipita- 
tion by alcohol the subsequent treatment 
with chloroform or ether- chloroform, by 



January 23, 1892. 



News and Miscellany, 



^59 



shaking with these menstrua, becomes 
impossible, owing to the formation of 
emulsions.) 

The evaporation may also be continued 
down to about 10 c.c. , and alcohol then 
added to 50 c.c. In this case, however, 
the sediment settles much slower and 
filtration is more difficult. 

After the sediment has been deposited 
the liquid is filtered. A measured por- 
tion of the filtrate is evaporated to 10 c. c. , 
transferred to a separatory funnel, i c.c. 
of ammonia water added, and shaken 
with 40 c.c. of ether-chloroform (15 c.c. 
of chloroform + 25 c.c. of ether). 
Tw^enty cubic centimeters of the ether- 
chloroform solution are then removed, 
evaporated in a capsule, and triturated 
with one-hundredth normal acid. 

This method had been published by 
the author before, but since it has given 
him so uniform and accurate results, he 
has now republished it. 

The results obtained t>y the author are 
interesting also to us, since they show 
the average yield of alkaloid under 
several conditions. 



Amount of 
alkaloid in the 



[air dry 
! herb. 



Aconite herb 1 year old, cultiv | 3(50 

" wild (1890) 0.496 

" c iltiv. (1890) I 0.493 

Belladonna leaves, 1 vear old, cultiv... i 0.189 

■wild (1S90) ; 0.:-^09 

cultiv. (1890) i 132 

Eyoe yamus " -wild (18901 i 0.072 

" cultiv. (1890) i 0.063 

Stramonium " -wild (1890) i 0.-89 

" cultiv. (1890) : 231 



anhrd'i 
herb. 



0.417 
0.5S5 
0.602 
0.209 
0.4U2 
0.172 
C85 
070 
0.319 
0.2.55 



Amt. of 
water 

in the 
herb. 



13.55 
15.2 
17 74 
12 5 
28.25 
23.5 
15.4 
9.85 
9.6 
9.5 



PREVENTABLE BLINDNESS. 

Dr. C. D. Conkey, in an article in the 
Northzv ester 11 Lancet, on ' ' Preventable 
Blindness," April 15, 189 1, ably condenses 
much information in this compend, viz. : 

1. The largest proportion of blindness 
in the young can be prevented. 

2. The majority of cases of blindness 
develop in the practice of the general 
practitioner, in the course of the invasion 
of the grave diseases of childhood, or as 
a consequence to these, or as a result of a 
contagious leucorrhoea in the mother. 

3. To successfully prevent them, pro- 
phylactic measures should be adopted in 
all cases where danger is suspected, or 
where the e^x shows a tendency toward 
inflammator}^ action. 



4. The physician should be sufficiently 
acquainted with eye diseases to treat them 
skilfully when the eye becomes invaded. 

5. After all severe attacks of the dis- 
eases of childhood the patient's sight 
should be carefully tested before he is dis- 
missed as convalescent. 



NEWS AND MISCELLANY. 



ANOTHER BOGUS AMERICAN DIPLOMA. 

Recent numbers of American contem- 
poraries announce the arrest of a Dr. (?) 
Van Vleck on a charge of issuing bogus 
medical diplomas, his institution going 
under the name of ' ' The Medical Uni- 
versity of Ohio," a title which is danger- 
ously like that of The Medical College of 
Ohio, which, we are assured, is a com- 
paratively reputable institution. Unfor- 
tunately the state of public opinion in 
far-away Ohio is not favorable to the re- 
pression of adventurers of this sort, and 
the lay press is strongly in their favor, 
on account of the advertisements which 
the quacks are shrewd enough to deal 
round with a liberality bordering on pro- 
fusion. — Med. Press. 



WORSHIPPING MEDICINE BOTTLES IN 
BURMAH. 

A good story' is told by the Modern 
CJmrch. An eminent lady missionary in 
Burmah recently gave Dr. A. J. Gordon 
an instructive but somewhat startling 
chapter from her experience. In one of 
her tours, she said, she came upon a vil- 
lage where cholera was raging. Having 
with her a quantity of a famous pain- 
killer, she went from house to house ad- 
ministering the remedy to the invalids, 
and left a number of bottles to be used 
after she had gone. Returning to the 
village some months after, the missionary 
was met by the head man of the com- 
munit3% who cheered and delighted her 
by this intelligence : ' ' Teacher, we have 
come over to your side ; the medicine did 
us so much good that we have accepted 
3'ourGod." Overjoj^ed at this news, she 
was conducted to the house of her in- 
formant, who, opening a room, showed 
her the pain-killer bottles solemnh' ar- 
ranged in a row upon the shelf, and be- 
fore them the whole compam^ immedi- 
ately prostrated themselves in worship. — 
Rural and Colonial Druggist. 



i6o 



News and Miscellany. 



Vol. Ixvi 



INFLUENZA ABROAD. 

A noteworthy difference between the 
present outbreak of influenza and those 
experienced last spring and the original 
epidemic of the winter of 1889-90 is the 
comparative slowness of its diffusion over 
the countr}^ It is mainly confined to 
two widely separated parts of the king- 
dom — viz., Cornwall and the eastern 
counties of Scotland. The reports from 
the latter show that some towns and vil- 
lages in Forfarshire, Perthshire, Fifeshire 
and Kincardineshire have suffered se- 
verely. In Dundee, the epidemic is on 
the decline, as also at Arbroath, where 
it has been particularly severe. At 
lyochee it is reckoned that more than 1600 
cases have occurred during the past 
month, and twelve deaths are attributed 
to it. It has been ver}^ prevalent at 
Edinburgh, but it seems only to have 
appeared at Aberdeen quite recentl3^ It 
is remarkable that children are being 
attacked almost as much as adults. 
Abroad, it is reported to be very prevalent 
in St. Petersburg and Berlin, whilst at 
Hamburg last week it had reached 
" alarming proportions," and the weekly 
mortality of the cit}^ and its suburbs ex- 
ceeded the average b}^ 280. In France it 
is especially prevalent at Bordeaux, 
where many deaths among the aged have 
occurred. It has also, as will be seen 
from our correspondent's letter, appeared 
in Paris. — Lancet. 



COMPRESSED MEDICINE TO BE USED 
HEREAFTER IN THE ARMY 
AND NAVY. 

The army medical service is interested 
in a contract which was awarded at the 
War Department for a new system of 
carrying medical and surgical supplies 
for an army. Kver since the last Sioux 
campaign there has been a growing de- 
mand for a plan by which supplies needed 
by the surgeons could be placed in a more 
compact form than liquid, and carried 
with greater safety and economy. The 
result of the award is believed to be as 
near perfection as possible. In a small, 
light wooden chest, 23 inches long, 14^ 
inches wide, and 17^ inches high, are 
sixty square bottles, containing as many 
different kinds of medicine, but in com- 
pressed tablet form, none of them being 
larger than an ordinary peppermint 
lozenge. One of these lozenges or tab- 
lets contains all the necessary ingredients 
of a liniment, and when dissolved in an 



ounce of distilled water its healing pro- 
perties are the same as if it was in liquid 
shape and in a big glass jar. Some idea 
may be formed of the perfection to which 
the art of compression has been brought 
by the fact that, if the contents of this 
small brass-bound chest were liquefied 
and in their customary jars and bottles, 
they would occupy nearly one-half of the 
space of a regular freight-car. After all, 
however, fluid extracts and powders take 
up less space than compressed tablets. — 
Med. Rec. 



DIPHTHERIA IN MII.AN. 

The Nemesis of bad water supply has 
of late been conspicuous in the lyombard 
capital. We have drawn attention to the 
severit}^ of the typhoid fever visitation 
due to that cause. Now we have to refer 
to another hardly less severe — that of 
diphtheria. It is in the schools that this 
latter scourge has been most prevalent, 
and, as usual, we hear of its ravages long 
after its first appearance. It must have 
been in the spring that it began to assume 
an epidemic form, and it was at mid- 
summer that it numbered most victims. 
In April the cases were 67 ; in May, 65 ; 
in June, 76. Jul}^ witnessed a decline in 
the frequency of its attacks. There were 
51 in that month, 52 in August, and 33 
in September, when the schools were 
closed for the holidaj^s ; but in October 
the cases rose again to 45. During the 
present month the diminution in number 
has been maintained, and also, it is said, 
the gravity of the symptoms has percep- 
tibly declined ; but there is still diphtheria 
enough in the city to justify the most 
active vigilance on the part of the Ufiicio 
Sanitario, and the utmost anxiety in all 
interested in school management — parents 
and masters alike. A correspondent tells 
us of an outbreak of the disease in the 
Via Palermo, where a much-frequented 
scuola communale is situated. Six cases 
are already reported in that quarter. 
Milan has spent much on public build- 
ings, some of w^hich are among the finest 
in Europe. We have lately seen pro- 
posals to replace the fagade of her world- 
famous cathedral by a new one. But as 
long as her drinking water continues the 
prolific source of disease, we should think 
that improved sanitary works, including 
an aqueduct to put a sufiicient supply of 
acqua potabile within the reach of all her 
citizens, ought to take precedence of all 
others. — Lancet. 



ol. LXVI, No. 5. 
''hole No. 1822. 



A Weekly Journal. 



Established in 1853 by S. W. BUTLER, M. D. 



THE 

MEDICAL AND ZTJMl 
REPORTER 

EDWARD T. REICHERT, M. D., Editor, 

Entered as Second-Class matter at Philadelphia P. 0. P. 0. BOX 843, PHILA., PA. 




CLINICAL LECTURES. 

Gl. Frank Lydston, M. D., Chicago. 

Surgical Pyelitis, 161 

James M. Anders, M. D., Phila. 

Combined Cardiac Lesions, 164 

Testing Castor Oil, 165 

COMMUNICATIONS. 

Louis E. Blair, M. D., Albany, N. Y. 
Pathological Conditions of Nose and Throat 

as Causal Factors in Asthma, 166 

Histories and Summary of Cases, .... 169 

John D. McGirk, M. D., Philipsburg, Pa. 
Specific for " La Grippe," 172 

X. O. Wfrder, M. D , Pittsburgh, Pa. 

Peritonitis, 173 

Florence Mays, M. D., Philadelphia. 

Gumma of the Iris, 178 



The Action of Orexin on the Stomach, . 179 



SOCIETY REPORTS. 

Allegheny County Medical Society . . . 179 
Cocaine in Peritonitis, 186 

SELECTED F0RMULJ5, 186 

EDITORIALS. 

The Treatment of Phthisical Cough, ... 187 

BOOK REVIEWS, 189 

CORRESPONDENCE, 189 

PERISCOPE. 

Medicine 190 

Therapeutics 192 

Surgery 194 

Paediatrics . 195 

Obstetrics 196 

Gynaecology, 197 

Hygiene, 198 

Medical Chemistry 199 

NEWS AND MISCELLANY 200 




CH. M ARCH AND* S 

Peroxide of Hydrogen. 

(MEDICINAL) H2O2 (ABSOLUTELY HARMLESS.) 

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DR. E. R. SQUIBB, of Brooklyn, N. v. " On the Medicinal Uses of Hydrogen Peroxide." 

Gaillard's Medical Journal, N. Y. 

DR. ROBERT T. MORRIS, of New York. "The necessary Peroxide of Hydrogen.'* 

Journal of the American Medical Association, Chicago, 111. 

NOTE.— Avoid substitutes— in shape of the commercial article bottled— unfit 
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Ch. Marehand's Peroxide of Hydrogen (Medicinal) sold only in 4-oz., 8-oz., 
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REFERENCES: 

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B. A. F. Penrose, J. M. DaCosta, Charles K. Mills, James Tyson, and Dr. Lawrence Turnbull; Professor Wil- 
liam Osier, of Johns Hopkins University; W. C. Van Bibber, M. D., Baltimore, Md.; W. W. Lassiter, M. D., 
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Resident Physicians: J. WILLOUGHBY PHILLIPS, M. D., S. A. MERCER GIVEN, M. D. 

For farther information address 

BURN BRAE, Clifton Heights, Delaware Co.. Pa. 



THE 

MEDICAL AND SURGICAL 
REPORTER. 

NO. 1822. PHIIvADBLPHIA, JANUARY 30, 1892. Vol.. LXVI.— No 



CLINICAL LECTURE. 



SURGICAIv PYKLITIS. 



By G. FRANK LVDSTON, M. D., 

CHICAGO. 



Professor of the Surgicai. Diseases of 

THE GENITO-URINARY ORGANS AND 

Syphii^ology in the Chigago 
CoELEGE OF Physicians 
AND Surgeons. 



Gentlemen : — The first case to which I will 
direct your attention is one of considerable 
interest. The gentleman is forty years of age, 
and has been under my care continuously for 
the last four years. He consulted me origin- 
ally for a very tight and tortuous stricture in 
the bulbo-membranous region. This was en- 
tered with difficulty after several weeks' faith- 
ful endeavor. Dilatation to the size of thirty- 
two French was finally effected, and occasional 
dilatation has since kept the stricture in a 
most satisfactory condition. When I began 
treatment of the stricture he was considerably 
debilitated ; his digestion was bad, and he was 
suffering from numerous reflex phenomena 
of a neuralgic character, referable especially 
to the vesical neck, rectum, lumbar region. 
He had run down considerably in flesh. At 
no time during the treatment of the stricture 
were any unpleasant results of the dilatation 
noticeable. It w^as necessary as a preliminary 
to treatment by dilatation to incise the meatus. 
About a year after the stricture had been 
thoroughly dilated, the patient contracted a 
heavy cold and developed a slight cystitis, 
with a moderate amount of renal congestion 
and some albuminuria. The renal symptoms 
disappeared, but the urine never cleared up 
completely, although irrigation and local an- 
tiseptic treatment of the bladder, in conjunc- 
tion with the ordinary measures of internal 
treatment for controlling cystitis, were kept 



»• 5. 



wp continuously for a considerable time. Some 
months after the cystitis developed, treatment 
having meanwhile been stopped for a while, 
the gentleman brought me a sample of his' 
urine, which had assumed an appearance 
which alarmed him, and Avhich he claimed 
was getting perceptibly worse. On examina- 
tion I found an abundance of pus and caudate 
pelvic epithelium. I satified myself that I 
had to deal Avith a case of pyelitis secondary 
to chronic inflammation of the bladder. The 
bladder symptoms, however, did not return, 
nor had they at any time been severe. The 
pus in the urine increased in quantity, but 
there were no subjective symptoms. I finally 
succeeded in clearing up the urine to a great 
extent, but it all times contained a considera- 
ble quantity of pus. Exacerbations have oc- 
curred from time to time, but there has beert 
no coincident constitutional disturbance. At 
times the pus has been present in such 
amount that on standing fully two-thirds of 
the bulk has appeared to be composed of al- 
most pure pus. 

I hold in my hand a sample of the first 
urine which the patient passed this morningy. 
and you will notice that it is perfectly opaque 
and exceedingly thick, presenting the charac- 
teristic greenish-yellow appearance of pyuria^ 
You will observe there are no clots of mucus,. 
but the pus is evenly disseminated throughout 
the fluid, and presents wdiat might have been 
described as a "powdery appearance." If 
this be allowed to settle, it will be found that 
the supernatant fluid will not become clear. 
This is a peculiar feature of pyelitic urine^ 
and serves in a measure to distinguish cases 
of pyelitis from pure cystitis. Under the 
microscope there will be found in tliis urine 
(and I will be pleased to have some of the 
students examine it for themselves) an abun- 
dance of pus corpuscles ; and it is proper iu 
this connection to say something in a general 
way regarding the presence of pus in the urine 
in various conditions. 

Pus corpuscles occur in the urine in cases 
of various forms of chronic inflammation of 



Clinical Lecture. 



Vol. Ixvi 



the genito-iirinaiy tract. Under ordinary cir- 
cumstances it is impossible to distinguish them 
microscopically from mucous or chyle corpus- 
cles. JVccording to Peyer/ single pus corpus- 
cles occur in almost every urine, especially that 
of women. As a matter of fact, the corj^uscles 
described by Peyer are nuicous corpuscles. 
The clinical features of the case must be taken 
into consideration in the differentiation of pus 
and mucus, as the microscope alone will not 
serve to distingush them. Whenever the 
form of corpuscles presented by mucus and 
pus occur in large numbers in the urine, the 
presence of pus may be inferred. Pyui'ia is 
invariably an indication of acute or chronic 
inflammation of some portion of the genito- 
urinary system. The pus corpuscles are about 
double the size of blood corpuscles, are opaque, 
and finely granular, this granular appearance 
serving to conceal their nuclei which, how- 
ever, become visible on the addition of acetic 
acid. The pus corpuscles may be notched in 
appearance as a consequence of the shrink- 
ing of the corpuscular membrane. AVhen 
, the urine is strongly ammoniacal, the pus cor- 
puscles dissolve to a certain extent and coa- 
lesce into a mass, losing their form, so that 
the microscope develops only their nuclei. 
When urine containing pus is first voided, 
ccorpuscles may present under the microscope 
the peculiar ameboid movement of the leuco- 
-cyte. We find in these cases — in cases of 
•chronic inflammation of tlie genito-urinary 
tract — as a rule, more or less epithelium. 
Epithelium, however, is frequently in normal 
urine, being indicative under these circum- 
stances of the same changes that occur in the 
stratum corneum of the skin, ^'iz., the shed- 
ding of effete epithelium. This shedding of 
epithelium is not abundant under normal cir- 
'Cumstances. In the presence of disease it is 
increased. We therefore find in cases in 
which there is an abundance of pus or muco- 
pus an increased quantity of epithelium, the 
form of which depends upon the site of the 
■diseased process. 

In case of inflammation of the renal 
tubuli and urethra the epithelial cells are 
rounded. Epithelial cells from the vagina 
and bladder are of the pavement variety, 
often hexagonal in form, nucleated, and are 
not to be differentiated from each other. 
Caudate epithelial cells originate most often 
in the renal pelvis, this form of epithelium 
being sometimes spindle-shaped. It is the 
characteristic epithelium present in cases of 
pyelitis. In some instances of severe inflam- 
anation about the neck of the bladder, caudate 



1. Clinical Microscopy, Page 54. 



epithelial cells are exfbhated. Thus Peyer 
describes a case in which a large quantity of 
caudate epithelial cells were found in the 
urine after cauterization of the deep urethra. 
The clinical history of the case and the other 
pathological features of the urine must be 
depended upon for the deferentiation of the 
caudate epithelium from the vesical neck and 
that from the pelvis of the kidney. Pyelitis 
does not give rise to conditions of the urine 
which are absolutely pathognomonic of their 
origin, particularly if, as is frequently the 
case, vesical inflammation co-exists either as 
a secondary or primary condition. As is 
often seen, inflanniiation of the bladder may, 
b}^ simple extension, result in pyelitis ; while, 
on the other hand, the irritating product of 
inflammation of the pelvis of the kidney may 
induce secondarily vesical inflammation. 
There is a form of pyelitis resembling simple 
chronic catarrh of the bladder — and associ- 
ated frequently with the latter — which fre- 
quently occurs in gouty patients, in whom a 
sensation of uneasiness in the region of the 
kidneys in combination with the appearance 
of more or less muco-pus, and the characteri- 
stic caudate cells of the renal pelvis in the 
urine enable us to diagnose the case with 
some positiveness. In such cases, however, if 
the neck of the bladder becomes implicated 
in the inflammation, the presence of caudate 
cells loses its significance. In a general way, 
we may state that we have in pyelitis, pus, 
blood and epithelium in the urine, the char- 
acters var}dng with the acuteness, duration 
and cause of the inflammation. 

As I have alread}^ remarked, the pus is in- 
clined to be of a powdery consistency and 
more finely disseminated throughout the 
urine than is the case in chronic vesical in- 
flammation. It is, moreover, apt to be of a 
greenish color from the admixture of hsema- 
tin. I have recently seen a case in which an 
exacerbation of pyelitis occurred in a young- 
man who had suffered from stricture and 
vesical catarrh during the progress of malarial 
fever. In this case the urine had a most 
peculiar greenish hue, very similar to what 
might have been expected from the admixture 
of vegetable matter. 

It is unfortunate that these special features 
of pyelitic urine frequently lose so much of 
their significance from the frequent co-exist- 
ence of vesical complications. It must be 
remembered that abscesses in the vicinity of, 
and discharging into, the genito-urinary tract 
give rise to pyuria. In such cases the pro- 
fuseness and possible intermittency of the 
purulent deposit in the urine and it close 
resemblance to the pus discharged fi"om 



January 30, 1892. 



Clinical Lecture. 



163 



abscesses in other situations, should lead to a 
suspicion of the condition present. Even in 
cases in which the marked clinical features 
of the case serve as a guide to the correct 
diagnosis of abscess, the source of the i)us is 
overlooked. Thus I have recently had a case 
in which I operated successfully for an 
abscess secondary to disease of the hip-joint, 
Yv^hich had discharged into the bladder, the 
eause of the pus appearing in the urine in 
this case having been overlooked by several 
competent surgeons. 

A case was recently referred to me of a 
woman who suffered from chronic inflamma- 
tion of the bladder with a discharge of an 
immense quantity of pus in urine. This case 
upon investigation proved to be one of pelvic 
inflammation with consequent abscess which 
had opened into the bladder. Cases of this 
kind must be taken into consideration in 
estimating the source of the pus in pyuria. 
During the progress of the case under con- 
sideration, there have been at various times, 
during the periods of transient renal conges- 
tion, mucous and granular casts in the 
urine. ° 

There has been until recently an abundance 
of caudate epithelium. I think it will be 
found, however, that in the specimen which 
I present to you this morning, no pelvic 
epithelium will be found and no casts. The 
renal structure proper is apparently in very 
good condition, but the pelvic epithelium has 
probably been so extensively destroyed that 
its absence from the urine at this time is very 
readily explained. Considering the quantity 
of pus in the urine it might naturally be ex- 
pected that this patient would be quite a sick 
man, but, strange to say, until mthin the past 
week he has not only been able to attend to 
his business, but has had a fair appetite, no 
pain or constitutional symptoms, and has 
received very little sympathy from his friends 
on this account. For the past week, how- 
ever, he has been running down, his appetite 
has failed, diarrhoea and night sweats have 
come on, and as he has expressed it, he has 
" suddenly gone all to pieces." I might 
state, that he has been treated in every con- 
ceivable way within the limits of rational 
therapeutics, and with only moderate success 
during the several years that he has been 
under my observation. I am going to try in 
this case the effect of hypodermatic injections 
of chloride of gold and sodium. 

I shall give for the night sweats Dover's 
Powder in five grain doses, Avith every ex- 
pectation of success from its administration. 
I shall continue the administration of qui- 
nine and iron and cod liver oil, and shall 



put the paitent upon three milk punches per 
diem. 

Subsequent Course of Case. — Gentle- 
men, you will recall the case of a patient with 
pyelitis whom I presented to you six weeks 
since, and to whom I informed you that I 
was going to administer the chloride of gold 
and sodium hypodermatically. The progress 
of the case has been most satisfactory, and as 
an evidence of it I present to-day a sample 
of this morning's urine. You will notice that 
it is almost clear. If allowed to settle it 
will be found that there is a very thin layer 
of purulent deposit on the bottom of the 
bottle. The patient is getting very fat ; his 
pyuria is checked, and his night sweats have 
yielded to the use of the Dover's Powder. I 
might remark in this connection that you 
will find the Dover's Powder to be the most 
reliable remedy at our command for colliqua- 
tive sweating, no matter what its origin may 
be. 

I experimented quite extensively while an 
interne in the New York Charity Hospital 
upon the abundant clinical material in our 
medical wards to determine the relative value 
of the various remedies recommended for 
night sweats, particularly in pulmonary con- 
sumption. I found atropine not only un- 
relialDle but productive of ceitain disagree- 
able effects that more than counterbalanced 
its possible advantages. The mineral acids 
and other tonic remedies and astringent 
baths were not much more efficacious than 
the atropine, although, perhaps, not so objec- 
tionable in some directions. I established, to 
my own satisfaction, the fact that there are 
but two remedies which can be relied upon 
to check night sweats. These are the Dover's 
Powder and the active principle of cocculus 
indicus or picrotoxin, the former being by 
far the more valual^le of the two. 

With regard to the improvement in this 
case, I am satisfied that the administration of 
both chloride of gold and sodium hypoder- 
matically is entitled to credit. I rather 
hesitate in making an arbitrary statement 
regarding the efficacy of this drug, particu- 
larly as its administration is just now quite a 
fad. But certainly in this case its use has 
appeared to be attended by most excellent 
results. How the treatment has acted I do 
not pretend to say, nor do I claim a single 
case proves such. I do desire, however, to 
call your attention to the case particularly, 
and shall take the opportunity of reporting 
it for what it is worth, in the hope that the 
remedy may be duly tried in similar condi- 
tions by other practitioners. It is but just 
to say that I have been using the drug for a 



164 



Clinical Lecture, 



Vol. Ixvi 



few weeks in several other cases of a milder 
type of inflammation of the genito-urinary 
tract, without having obtained as yet an 
appreciable effect. That the remedy has 
been in this particular case of valuable 
service as a tonic and alterative, and that it 
has had a special action on the affected 
structures is, to me, quite apparent. I do 
not, however, claim to entirely eliminate the 
possible element of coincidence in this solitary 
case. Further than what I have stated I do 
not pretend to explain the action of the 
drug. 

I will not at this time expatiate upon 
calculous, tubercular and other forms of 
surgical pyelitis, with their attendant features 
of pyo-nephrosis, changes in the renal tissue, 
characteristic of the various forms of so-called 
SLirgical kidney perinephritic abscess, etc., 
but will reserve these topics for future con- 
sideration. 



COMBINED CARDIAC LESIONS. 



By JAMES M. ANDERS, M. D., 
Profkssor of Theory and Practice of 
Mfdicinf, C1.1NICA1, Medicine, and 
Hygiene at the Medico- 
Chirurgicai, C01.1.EGE 
OF Phii,dei.phia. 



Gentlemen : — I am anxious to call your 
attention to a case illustrating conditions that 
the books do not have much to say about, 
namely : combined forms of cardiac disease. 

In most text-books on the practice of medi- 
cine, you will find very little said upon com- 
bined forms of heart disease, and in a great 
many of the best works there is nothing 
whatever on the subject. 

Now, we know that in a great many cases 
of aortic valvular diseases, for instance, we 
have mitral diseases follomng. Let us bear 
that in mind. We know that in a great 
many cases of mitral disease we have, later 
on, incompetence in the right side of the 
heart, of the tricuspid valve, and in other 
cases disease of the mitral valve co-exists 
mth or precedes the disease of the aortic 
valve, the one condition entirely independent 
of the other. So we ask. What influence has 
the disease at one valve upon the progress of 
the disease at the other and upon the symp- 
toms of that disease ? These are questions of 
vital importance. 

When you have combined forms of heart 
disease you will, as a rule, notice that the 
lesion at one of the valves stands out quite 
prominently as compared with the physical 



signs or the lesions of other valves. Some- 
times, however, you will have the trouble at 
one valve manifesting itself quite as well as 
at the other, and in these cases you will have 
frequently great difficulty in making a correct 
diagnosis and in giving a rational prognosis. 
Bear in mind that you will meet mth them 
in practice, and that they will give you much 
more trouble than cases of simple valvular 
lesion. 

We find that the woman before us, H. R,.,. 
age 25 years, is married, has had three chil- 
dren, and no miscarriages. Father is dead, 
mother is well except for an occasional cold. 
The patient has always suffered with sore 
throat on taking cold. Five years ago she 
had her tonsils cut, after Avhich the throat 
improved. A year later she had an attack 
of suppurative quinsy. Abut a year after 
she was attacked with a feeling of fulness in 
the median line of the thorax. This is still 
present and seems to start from the stomach 
and result in severe joain, which frequently 
extends to the forehead and right arm. The 
pain occasionally causes nausea and vomiting, 
which has occurred from twice a iteek to 
once in tivo weeks. The pain is especially 
severe at night, having caused her to rise 
from bed two or more times every night for 
the last three years. There is no specific 
history : appetite is capricious, bowels cos- 
tive, tongue clean. 

You may remember that on making a 
physical exploration of this chest we found 
several heart murmurs. We found what we 
thought was a presystolic murmur at the 
apex, a systolic murmur at the same place, a 
systohc murmur at the base, and a diastoHc 
murmur also at the base, making four mur- 
murs. Bear in mind what I said a moment 
ago about the lesions of one valve standing 
out prominently. So we find here that the 
murmurs and the symptoms which corrobo- 
rate aortic disease seem to predominate over 
those at the mitral valve. We have here a 
loud, harsh murmur, heard over the second 
inter-space to the right of the sternum. We 
find it transmitted very clearly through the 
carotids. We find it, hoAvever, present over 
the whole upper portion of the sternum. The 
fact that you hear it over the whole upper 
portion of the sternum does not mean that it 
is not due to aortic stenosis — it is aortic 
stenosis. But that murmur which is heard 
all over the upper part of the chest, and is 
systolic in rhythm, must, if it is due to aortic 
stenosis, be heard in the carotids, and this is 
the case here. We also heard a murmur 
with the second sound, a post-systolic or di- 
astolic murmur in the same situation. It is 



January 30, 1892. 



Clinical Lecture. 



165 



almost continuous with the sound we heard 
that is systolic ; was shorter in duration and 
nauch less marked, but being diastolic in 
rhythm, it must be due to regurgitation at 
the aortic valve. It is made by the recoil of 
the aorta causing the blood to flow back into 
the left ventricle. 

An interesting point about cases of this 
kind is this : You have a double murmur at 
the aorta. Which lesion predominates, the 
stenotic or regurgitant ? Bear in mind, you 
may have extensive regurgitation and yet 
have but a feeble regurgitant murmur. You 
listen over the carotid artery, and if you find 
that with the first sound you have a strong 
murmur — a strong aortic stenotic murmur — 
and a comparatively feeble regurgitant mur- 
mur in the same situation, as in the case be- 
fore us, you are justified in saying that 
stenosis predominates over regurgitation. If, 
on the other hand, you find a murmur that is 
about as well marked during diastole as sys- 
tole, or if you hear a diastolic murmur dis- 
tinctly over the carotid artery, and that mur- 
mur is preceded by a systolic murmur, then 
you are justified in believing that the regur- 
gitant predominates over the stenotic lesion. 

So in this case Ave have well marked mur- 
murs over the aortic valves, but Ave also have 
a systolic and presystolic murmur at the apex. 
Bear in mind that from extension of inflam- 
mation we may hav^e aortic disease, leading 
to mitral disease, or the blood pressure of 
aortic regurgitation may lead to mitral in- 
competency. In this case the aortic lesion 
seems to predominate (the aortic stenotic 
murmur predominating oA^er the aortic regur- 
gitant), and as a natural consequence the 
mitral trouble following the aortic. In other 
words, Ave had aortic stenosis, then regurgita- 
tion, the condition leading to mitral regurgi- 
tation, and finally stenosis. 

Not often do books speak of mitral stenosis, 
folio Aving regurgitation but I have found it so, 
although the rcA^erse is more often the case. 
At all events, Ave have four distinct mur- 
murs. Can you make out four distinct 
lesions in such cases? Certainly. You 
cannot rely in these cases upon the sym- 
ptoms, nor upon the changes that have 
been produced in the cardiac muscle. For 
instance, if you have mitral stenosis by 
itself you have not enlargement of the left 
ventricle, but rather the reverse, a feeble im- 
pulse beat because less blood gets into the 
ventricle, and you haA^e an ani^emic appear- 
ance because less blood reaches the peripheral 
circulation. 

You have that same lesion occurring with 
aortic regurgitation. The blood floAvs back 



into the left ventricle, and this, together with 
the current from the auricle, causes the ven- 
tricle to dilate on account of the increased 
amount of blood flowing into it; and to hyper- 
trophy from the increased Avork. Hence it 
is that in all these cases we have a hyper- 
trophied as Avell as a dilated ventricle. You 
would not look for a small left ventricle 
simply because you have stenosis in this case. 
So you cannot rely upon the changes pro- 
duced in the cardiac muscle where you have 
combined forms of heart trouble. You can- 
not rely upon the subjective symptoms be- 
cause the symptoms of one trouble simulate 
those of others in heart diseases, and because 
they are modified by tAvo or three different 
lesions. The one thing you can rely upon is 
the seat of maximum intensity of the mur- 
murs, their rhythm and area of diffusion. 
In everyinstance here you can confirm the 
diagnosis by listening to the murmur. 

I Avould like to tell you something about 
the influence of disease of the aortic valve, 
upon disease of the mitral valve, tell you 
something as to hoAV disease of the aortic 
valve modifies the prognosis and treat- 
ment of mitral valvular disease, and other 
subjects that are of interest and importance 
to you, and that are hardly touched upon in 
the text books, but time will not permit. 

We, at first, gave this girl for her double 
lesion digitalis, which seemed to distress her 
more. I ordered her this because she had 
oedema and evidences of broken compensa- 
tion. To-day Ave find she has not oedema of 
the feet. Compensation remaining unbroken 
there is no reason for increasing the force of 
the contraction of the left ventricle. We 
have, therefore, taken her off" digitalis and 
are noAV giving her iron, Avith the idea of 
feeding her heart muscle as much as possible, 
and additionally are treating the catarrhal 
condition of her stomach. That catarrhal 
state was due to trouble at the mitral value. 
She has not vomited since she Avas last here, 
the stomach being in much better condition, 
while all the other symptoms are much im- 
proved. 



TESTING CASTOR OIIv. 
To detect cotton-seed oil in castor oil, 10 
grams of the suspected oil are mixed Avith 6 
grams of a reagent made with 5 grams nitrate 
silver, 1 gram nitric acid, 100 grams alcohol, 
heated to 100° C. on water bath. In presence 
of cotton-seed oil the mixture assumes a red 
color after five minutes. — Apoth. Ztg. 



Communications. 



I Vol. Ixvi 



COMMUNICATIONS. 



PATHOIvOGICAL CONDITIONS OF NOSB 
AND THROAT AS CAUSAL FACTORS 
IN ASTHMA, WITH A RKPORT 
OF SUCCESSFUL CURES OF 
ASTHMA* 



By LOUIS E. BLAIR, M. D , 

AI^BANY, N. Y. 

As the title indicates, it is not the purpose 
of this paper to discuss at length all the 
various ideas which have at different times 
been advanced by the many writers on the 
subject of asthma, or to re^dew the several 
theories which have been faithfully followed 
for a time, and then discarded for 
others no more satisfactory in their results. 
. What interests us directly is : How far do 
abnormal conditions of the nose and throat 
cause or modify asthma ; and in what relation 
do the corrections of these pathological con- 
ditions contribute to a cure ? 

I think a new landmark in this subject 
was established when Weber, in 1872, dis- 
puted the bronchial muscular spasm theory 
of all previous writers. Salter, how^ever, in 
his extensive researches believed that asthma 
was essentially a neurosis, and this effect was 
directly exerted on the cells of unstriped 
muscular fibre in the bronchial tubes, caus- 
ing a spasmodic contraction of the same. If 
we consult the highest authorities, such, for 
example, as Duane's Dictionary of Medi- 
cine, Reynold's System of Medicine, and 
Pepper's System of Medicine, we find a defi- 
nition of asthma which is quite vague, while 
nothing is said for its pathology or even sur- 
mised as to its real cause. They have all 
essentially followed Salter, but none explain 
satisfactorily the moist second stage, which 
seems to be due to something else besides 
muscular spasm solely. 

Theodore Weber advanced the theory that 
the cause of the paroxysm lay in the paresis 
of the vasomotor nerves presiding over the 
vessels of the bronchial mucous membrane. 
He claimed "that under the influence of 
this vasomotor paralysis there occurs, from 
some cause, a sudden letting up of the con- 
trol which is exercised over the calibre of the 
blood vessels, whereby they become distended 
to such an extent as markedly to interfere 
mth the passage of air through the bronchial 
tubes. This paral}i;ic condition having lasted 
a certain length of time, the membrane 
maintaining a dry condition, as is always the 

* Bead before the Albany County Medical So- 
ciety, Albany, N. Y., Dec. 30, 1891. 



case in the first stage of the inflammatory 
processes, gives way and there follows an 
escape of serum and sero-mucus, thus reliev- 
ing the engorged blood vessels, which soon 
regain their normal calibre, coincident with 
the cessation of the paroxysm," This theory, 
says an eminent writer, completely harmon- 
izes, not only with the clinical history - of 
asthma, but with the clinical history of the 
paroxysm. It also favors the nervous cause. 

Weber could not assign clearly the dis- 
turbing causes which set up this irritation 
and prolonged it so as to modify the func- 
tions of the puenmogastric nerve ; however, 
his paper set other observers to thinking. 

A purpose of this article will be to show 
how the vasomotor nerve supply in the 
bronchial tubes is naturally disturbed by 
seemingly remote causes, and by virtue of 
the anatomical relations Avhich exist in the 
upper air passages. Let us look then, in 
passing, at the relations of the mucous mem- 
brane and nerve supply of the nose and 
throat to the lungs, and notice how it is 
reasonable to suppose that disturbances here 
can remotely produce such serious paroxysms 
as are found in asthma and hay fever. This^ 
condition is a reflex neurotic one, which is 
clearly demonstrated by the systemic effects 
which sprays of cocaine have on the mucous 
surfaces of the nose and throat; and hkemse 
the use of ether, chloroform, morphine, etc., 
in overcoming an attack. Dr. Jacobi stated 
in a recent discussion before the jSTew York 
Academy of Medicine that " he had seen at 
least a dozen cases of chorea which had no 
other cause than chronic nasopharyngal 
catarrh, deviation of the septum, ozsena, 
hypertrophy of the tonsils, etc. ; " and Dr. 
Baruch remarked : " The first positive case 
which removed my scepticism on the reflex 
influence of nasal peripheral irritation, is a 
cure of true epilepsy." He traced the cause, 
as he believed, in the nose, and by removing 
the cause he cured his patient. 

The nerve supply in the nasal cavities, 
apart from the special nerve of sense, is 
derived almost entirely from the spheno- 
palatine ganglion (Meckel's ganglion), the 
largest of the cranial ganglia, and a part of 
the sympathetic nervous system. This gang- 
lion also distributes branches to the throat, 
the head, and soft palate and eustachian 
tube. Connected with the three divisions of 
the fifth pair are the four small ganglia 
which form the cephalic portion of the sym- 
pathetic system. Meckel's ganglion is con- 
nected with the second division. All the 
four receive sensitive filaments from the 
fifth, and motor and sympathetic filaments 



January 30, 1892. 



Communications. 



167 



from various sources. The ganglia are also 
connected with each other and Avith the 
cervical portion of the sympathethic. 
Meckel's ganglion is by the videan nerve 
connected with the facial and the carotid 
plexus and the pneumogastric. From this 
anatomical description the sympathetic nerv- 
ous relations whicli exist between the nose, 
throat, eye, ear, larynx, and bronchial tubes 
will readily be seen.— (Gray, Allen and Mc- 
Clelland.) 

Van Loven proved experimentally that 
irritation of the sensory nerves is followed by 
reflex engorgement of the territory to which 
they are distributed. Sexton (The Ear and 
its Diseases, 1888, page 82) says this of the 
sympath}^ of the nerves : " In certain condi- 
ditions of the system the nerves become ex- 
ceedingly impressible to excitation. Thus, 
the irritation produced by the introduction 
of a speculum or a probe in the external 
auditory canal will excite coughing, or a 
desire to swallow and various other sensa- 
tions in the nose, throat or larynx. Many 
persons can locate the seat of local irritation 
thus propagated in the ear in some particular 
spot in these parts, the sensation being 
described as burning, tickling, and the like. 
There is very often an increase in the secre- 
tion of mucus in the spot thus irritated. 
When nerve tension has been long disturbed 
in this way, reflex phenomena are easily ex- 
cited ; continuous aural, nasal, or dental irri- 
tation, even if imperceptible, may affect one 
part or another until nutritive (trophic) 
changes are brought about." Now what 
Sexton has said of the ear and its relations, 
the same may be said of the upper air pas- 
sages and the bronchial tubes. Just as 
surely as a disturbance in the stomach will 
call forth an asthmatic attack in the proper 
subject, so also will a seemingly slight offence 
often, by dust, atmospheric conditions, or 
otherwise, have its weighty effect on the 
sympathetic nervous system, though the 
spheno-palatine ganglion and other nerve 
connections as instanced. 

Bartholow, in discussing the pathology of 
bay fever, one form of asthma, has this ana- 
tomical explanation to offer: "The sneez- 
ing, the asthmatic symptoms, and other 
nervous phenomena, are purely reflex effects, 
readily explained by the anatomical rela- 
tions of the affected nerves. Vulpian had 
long ago shown that ablation of the sphe- 
no-palatine ganglion, a centre of the sym- 
pathetic nervous system, was speedily 
followed by profuse catarrh of the nasal 
mucous membrane. The nucleus of the 
fifth nerve has close physiological relations 



with the nucleus of the pneumogastric nerve. 
Hence a reflex disturbance originating in the 
terminals of the fifth, may thus involve the 
terminals of the pneumogastric and its asso- 
ciated nervous conditions, causing amongst 
other nervous disturbances asthmatic symp- 
toms." 

Having noticed the anatomical relation ^- 
and close sympathy existing in the nose, 
throat, and bronchial tubes, the results of the 
theories of Weber will now be taken up, and 
the further development briefly reviewed, 
Valtoline in the same }Tar reported a case of 
asthma, whicli was })romptly cured by the 
removal of nasal polypi, showing' a sufficient 
cause from reflex nasal irritation. Hack, of 
Freiburg, Germany, shortly after claimed 
that there were certain definite " centres " of 
irritation capable of producing uniform reflex 
phenomena, such as occur in asthma, and 
suggested that the anterior extremity of the 
lower turbinate especially was the region 
which, in all asthmatics, ought to be removed. 
His radical theory was not accepted in full, 
but was productive of good in adding a new 
idea to further nasal investigations. Before 
Hack's valuable work appeared, Daly, of 
Pittsburg, read a paper before the Congress 
of the American Laryngological Association 
in New York, in 1881, upon the subject of 
hay asthma in its relation to nasal and 
neurotic factors. That paper seems to have 
been epoch-making in the study of this sub- 
ject. He attributed the annual recurring at- 
tacks " to local chronic disease, upon which 
the exciting cause acts with effect," and 
among other things he said : " The parts 
should be put in order and there])y enable 
them to withstand the exciting influence of 
the next recurring crop of bacteria." To 
criticise Daly's view^s, with all due respect 
for his other valuable suggestions, as he was 
the first to call attention to the condition of 
the upper air passages, it might be said that 
his language is soraew^hat vague and indefi- 
nite when he speaks of bacteria as exciting 
influences. Bacteria have nothing to do with 
the case. His theory was, to a great extent^ 
borne out in practice, and while he did not at 
that time fully comprehend the full signifi- 
cance of his new ideas, still he saw his cases 
do well. Just as soon as the nose and throat 
were put again into a normal condition the 
attacks of hay fever were relieved and, in- 
many instances, cured. Daly, however, only 
thought that this treatment applied to a 
special kind of ailment, and he did not in- 
dicate anywhere that it had reference ta 
asthma in general. Other writers soon elab- 
orated his ideas, and Roe, of Rochester, was 



i68 



Communications . 



Vol. Ixvi 



tlie next to add " that hyperiesthesia is asso- 
ciated \ntli, or occasioned by, a diseased con- 
dition, either latent or active, and that the 
removal of the diseased tissue in the nasal 
passages removes the susceptibility of the in- 
dividual to future attacks of hay fever." In 
the same year Sajous wrote independently 
-of Roe, and believed " that hay fever was due 
to an idiosynocrasy on the part of certain in- 
dividuals to become affected by certain ema- 
nations;" that "organic alteration of the 
surface of the nasal mucous membrane al- 
tered its sensibihty, and destroyed what mor- 
bid irritability might have attended the 
nervous filaments distributed over it," and 
also that " hypertrophies of the nasal mucous 
membrane increased its irritability and the 
intensity of the symptoms." 

in 1884, Mckenzie, of Baltimore, sug- 
gested the term " coryza vasomotoria period- 
ica," on the ground that " the disease is es- 
sentially a coryza, showing, in most cases, a 
decided tendency to periodic recurrence, and 
dependent upon some functional derangement 
of the nerve centres as its predisposing 
cause, and for the production of a paroxysm, 
-a certain excitability of the nasal cavernous 
tissue is necessary (brought on by a multitude 
-of external irritating causes), plus a hy- 
jperfesthetic state of (probably) the vasomotor 
centres." 

He, like the previous writers, had nothing 
to say for asthma in general, having only hay 
fever in his mind's eye. 

8ir Andrew Clarke, in 1885, formulated 
tis ^devv^s as follows, which seem to compre- 
hend the scattered opinions of others before 
Mm, and which, in a great measure, harmon- 
ize them. According to his theory there is 
(1) A neurotic temperament (the views of 
JBeard, Bleckley, and others) ; (2) a 
local condition of irritabihty, or positive 
pathological changes in the upper air pas- 
sages (the views of Daly, Roe, Sajous, Allen, 
McKenzie), and (3) an external exciting 
cause. 

Roe, of Rochester, in the Xeiv York Medi- 
eal Journal, 1887, summarizes an article on 
■hay fever, and among his conclusions he 
says : (1) That all cases of hay fever have 
their initiatory lesion in a diseased condition 
of the nasal fossae; (2) that the disease of 
these tissues induces in the ganglionic centres 
connected with them an abnormal activity, 
which is reflected to other tissues and organs ; 
"(3) that the disease in the nose may produce 
disease in other portions of the respiratory 
tract, which may become independent cen- 
tres of irritation ; (4) that the affection is 
not jyer se a neurotic disease, nor necessarily 



associated yvith a nervous temperament, al- 
though persons having a highly nervous tem- 
perament, or a neurosis, are much more sus- 
ceptible to the influence of a local irritant. 
Roe further says " that the neurotic condition 
which is often regarded as a cause of hay 
fever, is itself often developed as the result of 
the local irritation. These views differ 
widely, of course, from those held by Clarke 
and many others. Morrell McKenzie is more 
conservative. He says : " While admitting that 
many reflex phenomena may arise from dis- 
ease within the nose, I must caution the 
younger specialist that the various complaints 
referred to as resulting from nasal disease are 
much more frequently due to other condi- 
tions, and that every other possible cause 
must be eliminated before the nose is incrimi- 
nated." 

Up to 1887 no writer endeavored to show 
that perennial asthma and hay asthma had 
anything in common. All the previous 
writers tried to solve the problem of hay 
fever, and had nothing to say for perennial 
asthma, for they saw no relationship between 
them. Bosworth made a further advance. 
He showed in an exhaustive and most valu- 
able essay that, according to a vast clinical 
experience and painstaking observation, 
hay asthma and perennial asthma, as he 
classified the latter to distinguish it from the 
former, were, as he believed, but two sub- 
di^'isions for the general term asthma. To 
hay asthma he gave the name vasomotor 
rhinitis, and to perennial asthma, vasomotor 
bronchitis. With reference to the existence 
of the intra-nasal disease, he found such to 
exist in every case, and to such an extent as 
to point conclusively to its strong causative 
influence in producing a paroxysm of asthma. 
He says such conclusions might easily be 
questioned, but thinks his argument is good 
when of the eighty cases he had, forty-six 
were cured, twenty-six w^ere improved ; and 
this v\'as entirely due to the result of treat- 
ment of the nasal disorder. And he further 
reasons that, if the attack of asthma is cured 
by curing the nasal disorder, the asthma 
itself is caused by the nasal disorder. He 
also believes that the neurotic habit has also 
a great causal influence, and this nervous 
condition must not be lost sight of in the 
treatment. Bosworth further says : It is not 
yet an axiom that every individual of neuro- 
tic habit, who suffers from an obstructive 
lesion in the nose, will necessarily hav^ 
asthma. However, he believes very often 
asthma is present in a mild degree, and a 
careful diagnosis not being made, the distress- 
ing symptoms are referred to a supposed 



January 30, 1892. 



Communications . 



69 



attack of bronchitis. And so the asthmatic 
habit is insidiously formed, and only when 
it is worse does it become manifest. In 
conclusion, he says, he believes three factors 
enter into the causation of asthma, viz., 
(1) A neurotic habit; (2) the nasal dis- 
order ; and (-3) atmospheric conditions — the 
nasal disorder far outweighs in importance 
not only the nervous, but all other elements. 

At least seven months before I sav\^ Bos- 
W'orth's article, I was treating perennial 
asthma in precisely the same ^vay as this 
author, and as I had been treating hay fever, 
and reasoned from the close anatomical rela- 
tion of the upper air passages to the bronchial 
tubes that the diseases were quite analogous 
and very likely but different manifestations 
in different individuals with certain modify- 
ing influences of heredity diathesis, etc. I 
desire to quote a few lines from a letter 
written to the father of a little patient I 
treated, who lived in Texas, and who was 
desirous of learning what I thought of his 
child's case and w^iat my ideas were as to the 
plan of treatment, and what could be looked 
for. The history of this case will be given 
shortly. I explained to him briefly the close 
sympathy anatomically existing, and how all 
the symptoms in his boy's case clearly pointed 
to the nose and throat as being the seat 
of most of the trouble. These sentences 
occur in the letter : " By treating all diseased 
conditions found in the nose and throat and 
by building up his strength with suitable tonics, 
etc., in this way, I think, a great deal may be 
done for your boy. It appears to me to be 
by far the most promising plan of treatment 
yet suggested, as it aims to remove causes 
and sources of irritation." This patient was 
entirely cured of an asthma which he liad 
since birth. 

I think the fact which has not been pro- 
perly brought out by previous writers is the 
exposed j)Osition, so to speak, of the sym- 
pathetic nervous system in the upper air 
passages through Meckle's ganglion and its 
numerous connections. All pathological con- 
ditions here, whether in the form of deflected 
septum, nasal spurs of bone causing contact, 
enchondromata, polypi, hypertrophic rhinitis, 
etc., may have a direct disburbing influence 
in causing asthma and hay fever, as has been 
fully shown. Various authors have queried 
about causes, and have hidden their indefinite 
explanations behind the terms "reflexes" 
and " reflex influences." Here, I believe, is 
a plausible anatomical reason clearly set 
forth, and it ought to be emphasized, that : 
Pathological conditions of the upper air 
passages have a causal relation in producing 



or influencing directly the lumen of the 
minute bronchial tubes causing the embarrass- 
ment in the respiratory function in the first 
stage of asthma, and the consequent catarrh 
in the second stage, so ingeniously claimed b}' 
Weber. So far as the vasomotor nerve centres 
are disturbed in the lungs it is easy enough 
to understand, by referring again to the ana- 
tomy of this system. Kirke's Physiology 
(Wood's Library, 1885, vol. 1, p. 254) says': 
" Experiments by Ludwig and others show 
the vasomotor fibres come primarily from 
the grey matter (vasomotor centre) in the 
medulla. Thence the vasomotor fibres pass 
down in the interior of the spinal cord, and 
issuing with the anterior roots of the spinal 
nerves, traverse the various ganglia on the 
prsevertebral cord of the sympathetic and ac- 
comj)anied by branches from the ganglia 
pass to their distributions. These nerves have 
direct control in modifying the calibre of the 
blood vessels. An increase of the blood 
pressure may be produced, among other 
causes, by stimulation (irritation) of the 
vasomotor centres in the medulla reflexly by 
stimulation of the sensory nerves anywhere. 

HISTORIKS AND SUMMARY OF CASES. 

This paper covers a period of observation 
of five years, and is based upon a study of 
the cases which have come under my notice. 
Most of these patients I have had under ob- 
servation since, and have been famihar Avith 
the results of treatment ; and have been able 
to verify the benefits Avhich in most cases have 
been obtained. I have the record of more than 
thirty-five cases of asthma and hay fever, but 
desire to note the histories of only three or 
four which are typical ones, and illustrative 
of the pathological conditions found in the 
nose and throat of such cases, and the method 
of treatment which was pursued. 

Case 1. Louis M , aged 11. Kesi- 

dence, Galveston, Texas. Has been a great 
sufferer from perennial asthma and hay fever 
for years, his asthmatic difficulty dating from 
the time he was two months old. Has tried 
all sorts of medication and treatment, includ- 
ing change of residence, both at the seashore 
and in mountainous regions. His mother said, 
to her knowledge, he had seldom been an 
entire month free from some of the distressing- 
symptoms of asthma. Being advised to try 
a Northern climate, as a last resort, she came 
to New York City and consulted Prof. Loomis. 
He gave her no encouragement after examin- 
ing her child, but thought that inasmuch as 
she was North she might try a mountainous 
climate, and suggested the Catskills. She went 
there, and during the six weeks she was at 



Communications. 



Vol. Ixvi 



Palenville slie said her boy never suffered 
worse, and was satisfied that it was not the place 
for him. She was very much discouraged, 
and was about to return to her home in Texas. 
Having relatives in Albany she paid them 
a visit before returning, and while here some 
one suggested my name favorably to her. 
She brought her boy to the office to see if any 
relief could be found for him. For days he 
had not been out of his clothing, his asthma 
being so bad that it was impossible for him to 
lie down. The dyspnoea was very urgent, 
and his whole comitenance plainly told what 
a sufferer he had been. Upon making a 
careful examination of the nose and throat 
the following abnormal conditions were found : 
Both nasal fossae were very nearly occluded, 
with enlargement of the middle and lower 
turbinated bodies, and pressing against the 
septum ; the naso-pharynx was almost filled 
with adenoids ; both tonsils were hypertro- 
phied, almost meeting the uvula in the mid- 
dle line ; the uvula was elongated and rested 
constantly against the lingual tonsil, which 
was also very prominent. What was espe- 
cially noticeable was the extreme sensitive- 
ness of certain portions of the mucous mem- 
brane of the nasal passages, especially over 
the cartilaginous septum and bones ; and if 
but lightly touched with a probe a severe 
coughing spell, with sneezing, would be called 
forth. Dust of any kind in the atmosphere 
would make him decidedly worse, and he 
had a perfect dread of being in or near 
a room where sweeping was done. He 
was troubled constantly with intense itching 
and burning in the nose, and the shghtest cold 
in the head would make his asthma worse. 
He was busy fussing with and rubbing his 
nose almost constantly. In fact he seemed to 
be all nose. Physically, he w^as poorly de- 
veloped, his chest was flattened and narrowed, 
as is characteristic of children suffering with 
adenoids of the nasopharynx and enlarged 
tonsils, both of which conditions rendering 
free breathing and hence perfect oxygenation 
impossible. His appetite was poor and his 
whole appearance denoted one of suffering. 
His weight was forty-seven pounds. I began 
to treat him September 1, 1889. The plan 
of treatment was to alter the hypersesthetic 
condition of the mucous membrane in the 
nose ; remove all abnormalities as far as pos- 
sible ; to correct the condition of things in 
the nasopharynx ; to remove the tonsils, etc. 

November 1. — Eight weeks after beginning 
treatment, I noted that his condition was 
considerably improved. The itching and 
burning in the nose, and tendency to cough 
and sneeze gone ; can sleep flat on his back 



now, for the first time since he was an infant ; 
appetite much better and has gained ten 
pounds in weight. 

December 10. — Has no more asthma ; eats 
and sleeps good, and has gained fourteen 
pounds. 

February 15. — The favorable gain contin- 
ues and has had no attacks of asthma. 

He continued to improve very perceptibly, 
and during the next eighteen months had 
only one relapse of asthma, due to an attack 
of bronchitis, brought on by gross careless- 
ness. He grew four inches in height and 
his weight was seventy-two pounds, a gain of 
twenty-five pounds. He was entirely cured 
of an asthma which he had, dating almost 
from his birth. 

Case 2. John G , 1) Delaware Street, 

set. 21, occupation wheelwright and black- 
smith. Has had asthma since he was five 
years old ; has had many severe attacks last- 
ing many days at a time. In the summer 
time has had frequent relapses of asthma, 
suggestive of hay fever, wliich would disap- 
pear again with the appearance of frost. His 
occupation as a blacksmith was very unfavor- 
able for his nose and throat, and when tlie 
air was filled with dust he always suffered 
with a relapse of asthma. He was only able 
to w^ork about one-third of the time. His at- 
tacks of asthma were so severe that there 
were many days consecutively that he could 
only find ease by sitting upright in a chair 
leaning on a pillow, resting his head on an- 
other chair in front of him. 

Examinations of nose showed hypertrophic 
rhinitis, and the usual sensitive spots and 
areas which have been so well pointed out by 
McKenzie, Daly, Roe and others. Touching 
these sensitive places would at once set up a 
fit of sneezing and nasal coughing, and if 
persisted in would provoke a slight asthmatic 
attack. It was also interesting to note in 
connection with the treatment that after the 
use of the cautery or an acid in the nose, the 
reflex irritation would produce usually a se- 
vere relapse of asthma, lasting very often for 
two days, which very clearly pointed out 
nasal irritation and its reflex disturbance on 
the nerve supply in the lungs. This has 
often been observed in other cases, and I 
have often told patients not to be surprised if 
their asthma would be at times worse im- 
mediately after treatment, and wherever this 
reactive asthma has been marked the result 
of treatment has invariably been good. 

Contrast with this the observation of R. 
H. Blaikie (Edinburgh) who- says : " In the 
case of reflex neuroses, due to nasal affec- 
tions, cocaine may be used to confirm the di- 



January 30, 1892. Communications. 



171 



agnosis, since the parts of the nasal passages 
to which it is applied Avill no longer be capa- 
ble of producing the symptoms, such as fits 
of sneezing, asthma, etc., Avhich their former 
condition set up. 

I began to treat this patient December 1, 
and twenty days after made the following note 
in my case-book: No asthma except after 
cautery and has gained ten pounds. 

March 1. — No more asthma since begin- 
ning treatment and has gained twenty pounds. 
Has not lost one hour from his work this 
winter by reason of sickness, something 
which he never did before. He was dis- 
charged cured. I saw him a year and a half 
afterward and he had gained eighty pounds 
in weight, and was a car builder at the West 
Albany shops. He considered himself phy- 
sically as well and strong as any man in his 
shop, and had not lost a single day from 
work by reason of his former malady since 
he stopped treatment. 

Case 3. Miss Mary K , ait. 13, a 

patient kindly referred to me by Dr. Town- 
send. She was suffering with hay fever and 
23erennial asthma, the latter, however, was 
quite mild, only showing itself when an acute 
attack of bronchitis would come on. She 
had been ailing with her asthmatic difficulty 
since her second year, and in her third sum- 
mer had real hay fever. Her parents tried 
all sorts of medicines and cures, change of 
climate, etc., but all to no purpose. She suf- 
fered intensely from a constant itching and 
burning in the nostrils, which extended to 
the eyes, and the Hds and surrounding tissues 
were actually ecchymosed from the severe 
rubbing and weeping, giving her face a very 
peculiar appearance. There was also a con- 
siderable conjunctivity, photophobia, etc., and 
together with the very sensitive condition of 
the nose, her feelings were anything but com- 
fortable. Examination of the nose showed : 
Eight side — septum anteriorly and low down 
an exostosis extending lengthwise backward, 
covered mth a mucous membrane exceed- 
ingly sensitive and in close contact with the 
lower turbinate, which was abnormally large. 
The pressure here by contact was a constant 
source of irritation, and had a very decided 
influence in keeping up this difRculty. The 
whole septum was exquisitively tender, and 
touching it lightly with a probe anywhere 
caused severe pain, lachrymation, and set up 
at once a paroxysm of sneezing and cough- 
ing. The middle turbinate was likewise hy- 
pertrophied and tender. Lefl side — hyper- 
trophic rhinitis is also marked, but the mucous 
surfaces not so sensitive. The method of 
treatment consisted in removing the exostosis. 



in separating the two sensitive surfaces from 
further contact, in obliterating the tender 
spots as far as could be determined ; to place 
the nose and throat in a healthy condition, etc. 

I began to treat her August 17, previous to 
which from June 1 she had been a great 
sufferer from all the usual and distressing 
symptoms. After the first treatment, which 
consisted in removing the exostosis from the 
septum, she had a severe relapse of asthma, 
and had others also due to the operation. 
Six weeks after the first visit all traces of 
hay fever and asthma were gone, and she 
has enjoyed unusually good health ever 
since. 

CA^^E 4. Bessie F , aged 9, a patient 

kindly referred to me by Dr. Gorham. Had 
a history of asthma dating almost from her 
birth, and suffered very much like Case 1, 

Louis M . The condition of the nose 

and throat was very much like that of the 
little boy, and her difficulty was a most 
obstinate one to relieve. After months of 
careful treatment her condition was but very 
little improved. Her general health was 
poor. 

However, I felt confident that as her 
general health would improve, her asthmatic- 
trouble would do better, and so predicted- 
There were many sources for reflex irritation 
removed, and judging from the success in the 
other cases, and taking into consideration her 
age, it was reasonable to infer that the old 
difficulty would be removed. Six months 
after I last saw her, I received a letter from her 
mother, saying that Bessie had never been 
so well, and was gaining constantly. 

CONCLUSION. 

I have thus dwelt at length upon the- 
various theories and views of writers in order 
to show what the advanced sentiment is in 
regard to this subject in medicine, which 
evidently remains to be written. Its present 
treatment by therapeutic -means alone is very 
unsatisfactory as every one will admit. Time- 
worn remedies have been discarded for newer 
ones more encouraging, and these in turn 
abandoned for others. There is no specific 
for asthma. Each case must be studied by 
itself. The ph3^sician must satisfy himself as 
to the integrity of the upper air passages, 
more especially the nasal cavities. Here is 
the most prolific cause of asthma, a fact 
which has now been fully proven by most 
careful writers, and by most successful and 
convincing records of treatment. In all of 
the thirty-five cases which I have treated,, 
abnormalities of the nasal cavities were veri- 
fied ; and those cases which were not bene- 



Communications. 



Vol. Ixvi 



fited, I believe, that other and remote 
nervous disturbances were influential in keep- 
ing up a reflex asthma. 

204 State St. 



SPKCIFIC FOR "IvA GRIPPK." 
By JOHN D. McGIRK, M. D., 

PHII.IPSBURG, PA. 



I wish to make a statement to the medical 
profession concerning my experience in 
the treatment of the prevailing epidemic, 
la grippe, or influenza, which is producing 
such a furor in the world, and in the treat- 
ment of which there seems to be nothing but 
confusion. The treatment of this disease, so 
far as a specific has been found, seems to 
have been given up by common consent. 
This was admitted a fcAV days ago by one of 
our eminent professors in a lecture to his class, 
and was pubhshed in the Philadelphia Times 
of the 6th instant. 

The number of remedies suggested has 
been very great, most of them useless, many 
unscientific, and some extremely foolish ; 
such, for example, is the treatment with 
whisky and quinine — a more unlikely com- 
bination to cure a disease like la grippe 
could scarcely be conceived. 

If this influenza is the same disease, and 
characterized by the same symptoms in 
Phiiipsburg, Pa., as it is everwhere else, 
and known by the common name of the 
*'grip," then I claim that the treatment I 
have been using is a specific in the fullest 
meaning of that word. I claim that the 
remedies I use will completely and perman- 
ently break up the disease in from eight to 
sixteen hours in every typical case, which 
I have seen verified in more than tAvo 
hundred cases of an unbroken record, and 
which I am now treating daily without a 
failure. The specific is a combination of fluid 
extract of aconite root and fluid extract of 
gelsemium. The aconite controls the fever, 
while we have in the gelsemium the most 
powerful febrifuge and anti-neuralgic remedy 
in the pharmacopoeia, and in the combina- 
tion of these two Ave have a therapeutic 
Hercules Avhich, in poAver and range of appli- 
cation, cannot, apparently, be equaled by any 
other drugs in the Avorld. 

Now let us apply the treatment. I see 
my patient, say at 9 A. M., an adult of 
ordinary size and physique, and listen to the 
folloAving history : " I felt chilly for several 
hours yesterday, then I began to have head- 
ache and pains all over my body, noAV I am 



burning up AA'ith fcA^er and my head is 
almost bursting, and my eyes pushing out of 
my head. My head feels as if there Avas a 
force pump inside of it trying to break 
through the skull. I never had such a head- 
ache in all my hfe — what is it doctor ? Is it 
Avhat they call the ' grip ' ? " 

The aboA^e is a fair sample of Avhat e\"ery 
doctor has heard. I noAv examine my pa- 
tient, and find a full bounding pulse (such as 
Avould indicate bleeding forty years ago) of 
from 100 to 140 pulsations to the minute ; 
skin very hot, it may be moist, but is usually 
dry ; temperature 102° to 105° ; skin, red ; 
face, flushed ; eyes, red, prominent and full of 
tears ; great thirst, and, perhaps, delirious, 
etc. This is the disease Avhich has been pre- 
vailing in our toAvn, and AA^hat Ave recognize 
as la grippe. I assure my patient of a 
speedy and permanent recovery. I take 
from my pocket case a Adal of fluid extract 
of aconite root and put three drops in a 
glass, and add tAvelve drops of fluid extract 
of gelsemium, a little Avater is added and 
this constitutes the first dose. I then order 
him to bed, Avith strict injunction not to leav^e 
under any circumstances. 

I am at his bedside again at the end of 
four hours ; find the pulse a little softer, not 
quite so frequent; the skin a little cooler and 
thirst not quite so great. I noAV give a smaller 
dose tAvo drops of the fluid extract of aconite, 
and ten drops of the fluid extract of gelse- 
mium, and I say to my patient: "I will 
see you again at the end of four hours, when 
in all probability you AAill be bathed in a pro- 
fuse perspiration, your headache and backache 
greatly relieved, and in cA^ery Avay feeling bet- 
ter, but under no circumstances remove any of 
your covering, lie still and SAveat until I see you 
again, drink no lemonade, but a swallow of 
cold Avater (not iced Avater) may be taken 
occasionally. 

When I see my patient again at the end of 
another four hours I generally find him in a 
profuse perspiration, headache all gone, or 
greatly reliev^ed, all pains and aches much 
better, pulse normal in size and frequency; 
temperature 98.5°. This is the end of his 
grip, as a rule, but in case I find on my third 
visit that the pulse is still a little full, and 
the perspiration slight (perhaps none, but 
this is very rarely so), I repeat the dose, two 
drops of the aconite and eight drops of the 
gelsemium, and on my next (third) Adsit, 
after another interval of four hours, I find the 
treatment has accomplished the great essen- 
tial, complete relaxation of the system and 
" restoration of equilibrium" in the circulatory 
and nervous systems, and there follows as a 



January 30, 1892. 



Communications. 



173 



necessity normal pulse, normal skin, normal 
temperature, normal respiration, and normal 
everything. A fourth dose is scarcely ever 
required, and I believe I have not found it 
necessary but in four or five cases out of more 
than two hundred. 

It is the combination and careful adminis- 
tration of these powerful remedies that I 
have found such perfect success following 
their administration in every case. A little 
backache may linger in a few cases for 
twenty-four hours thereafter, and a sense of 
soreness all over the body is, of course, to 
be expected for a while after convalescence, 
but a small dose of the gelsemium (three 
or four drops) removes the backache, whilst 
a rubbing of the body all over with the hand, 
and olive oil, is exceedingly grateful to the 
patient. This must be done by the nurse 
passing his or her hand under the bedding, 
in order to avoid any possibility of taking 
cold. The hand of the nurse must be warm 
and the oil as hot as the hand will bear. I 
used this remedy on " general principles " in 
the first case I treated in the epidemic of 
1889, and have used it in our present epi- 
demic, and have nothing more to desire in 
the way of a specific treatment. I know of 
no serious disease which yields so promptly 
and permanently, and which has engendered 
so many feelings of gratitude from my patients 
as in the treatment of this disease by old- 
fashioned, common-sense method. I have 
not had a case of pneumonia nor anything 
else following this disease. My patients get 
sound and well and remain so. 

A few precautions are necessary. The 
perspiration will generally last twenty-four 
hours or longer after the disease is broken 
up, and I forbid the patient getting out of 
bed for three days, and not to leave the 
house for a week. I give no purgatives 
prior to the third day of convalescence, and 
usually by that time they are not required, 
the bowels moving naturally. I seldom 
give tonics, as the appetite becomes ravenous, 
and digestion and assimilation perfect, which 
is the best of all tonics. I never prescribe 
this medicine for the patient to take him- 
self, and never leave a second dose with the 
patient to be taken at his own discretion. I 
give every dose myself, and never give a sec- 
ond until I am satisfied the former dose has 
done all it can, for I have frequently found 
a single dose accomplish all that is required. 
A possible idiosyncrasy on the part of the 
patient must not be forgotten. No toxic 
symptoms have manifested themselves in 
any of my cases, but the intelligent phy- 
sician will readily understand that he can- 



not be too cautious when handling such 
potent remedies in heroic doses. Profes- 
sional brethren, please try this treatment 
(following the directions to the letter) in genu- 
ine la grippe, the worse the case the better, 
and report results to The Medical and 
Surgical Eeporter. 

addendum. 

I have found that gelsemium alone is an 
abortive for la grippe in its milder form, 
when there is little or no fever. A general 
feeling of malaise, with wandering pains in 
the head, eyes, and body. What might 
with propriety be called grippy sensations. 
Two or three five (5) drop doses of fluid ex- 
tract gelsemium, repeated at intervals of 
two hours, will seldom fail to aflTord com- 
plete relief 

The distressing bronchial cough, with a 
sense of pain and oppression in the lungs 
and throat, which accompanies so many cases 
of influenza is soon relieved by mustard 
plaster on the chest and the following ex- 
pectorant mixture : 



Muriate of Ammonia c.p 5 iii 

Morphia Sulphate gr. iii 

Spiritof Chloroform §i 

Tr. Scillae 5 ii 

Pyr Senega § i 



Sp. Rock Oandy q. s. add S iv 

Mix. A teaspoonful in water every two or three hours. 



PERITONITIS." 
By X. O. WBRDER, M. D., 

PITTSBURGH, PA. 

While peritonitis, as a disease, was Avell 
known to physicians of all ages, a full know-" 
ledge of its pathology and an intelligent 
method of treatment is clearly the work of 
modern investigators. Its etiology particu- 
larly was very little understood until the 
phenomenal advances in abdominal surgery 
cleared the darkness and threw light into 
the mysteries hidden in the abdominal cavity. 
Hand in hand with the surgeon worked the 
pathologist, and their combined eflbrts 
brought about a revolution of our views of 
the disease and its treatment. In no branch 
of medicine has such wonderful progress 
been made as in that pertaining to the peri- 
toneum and the organs it invests. It is true 
this progress has benefited surgery much 
more than medicine ; so it appears that peri- 
tonitis, at least many of its forms, is rapidly 
becoming a surgical disease. The diagnosis 
of peritonitis does not satisfy the progres- 
sive mind of the modern physician ; he has 



* Kead before the Allegheny Medical Society, 
Nov. 17, 1891. 



174 



Communications. 



Vol. Ixvi 



learned the importance of striving to arrive 
at its cause and seat which, though con- 
tained in that large cavity invested by 
peritoneal membrane, may belong to any of 
the many organs located there. Peritonitis 
is, therefore, a general name for many dis- 
eases, differing not only in their symptoms, 
pathology and etiology, but frequently also 
in their treatment. They are only alike in 
as much as they are all accompanied by in- 
flammation of the lining membrane of the 
diseased organs, the investing peritoneum. 

To enter into a detailed description of all 
these forms of peritonitis avouM be a task 
impossible to me without transgressing the 
limits of my time. I, therefore, decided to 
confine my remarks to two large grouj)S of 
this disease which are by far the most fre- 
quent and important, the one afiecting with 
particular predilection the male sex, especially 
the younger portion of it ; the other is, ex- 
clusively, a female disease. I refer to peri- 
typhlitis or, more correctly, appendicitis and 
pelvic peritonitis. 

Formerly most inflammatory conditions in 
the right illiac fossa were regarded as a 
typhlitis or peri-typhlitis, the former being a 
catarrhal inflammation of the mucous mem- 
brane of the caecum, the latter an extension 
of this inflammation to its surrounding peri- 
toneal covering and especially of the retro- 
peritoneal connective tissue of the csecum, 
which was frequently accompanied by 
abscess formation in this retro-peritoneal 
tissue, caused generally by perforation of the 
caecum through its posterior wall. These 
collections of pus were, therefore, thought 
to be outside of the peritoneal cavity. Dis- 
ease of the appendix was much less connected 
with inflammation in the right iliac fossa. 
Within the last few years our views have 
experienced a decided change, principally 
influenced through the experience gained by 
the numerous abdominal sections made for 
this disease. Inflammation of the caecum or 
peri-typhlitis is now regarded as very rare, at 
least on the primary lesion, while appendi- 
citis is extremely common. McBurney says 
that in a hundred cases of inflammation in 
the ilio-csecal region, ninety-nine are cases 
of appendicitis. 

An appendicitis may be a simple catarrhal 
inflammation of the mucous membrane of the 
appendix vermiformis, causing few or no 
symptoms, excepting, perhaps, some slight 
tenderness over the region, which may be 
easily overlooked, accompanied by more or 
less disturbance of the digestive organs and 
often some febrile symptoms. The appendix 
in such cases generally contain small fecal 



concretions which act as irritants to the 
mucous surface and are accused of bringing 
on the inflammatory trouble, though in eight 
cases operated on by LcAvis A. Stimson in 
only one were there concretions of sufficient 
size to be justly blamed for the existing 
condition. Foreign bodies, such as cherry 
pits, grape seeds, etc., are much rarer the 
cause than was usually supposed, and accord- 
ing to Jacobi, it is probable that "few, if 
any, foreign bodies enter the process unless 
the latter has previously lost its elasticity 
and contractility by an inflammatory 
change." This catarrhal inflammation may 
be followed by a complete resolution and 
permanent cure, but in many cases frequent 
relapses occur. The appendix may not be 
able to rid itself of these irritating fecal con- 
cretions, or the previous inflammation may 
have left a stricture at its csecal orifice fol- 
low^ed by retention of its own secretion, 
which may give rise to renewed attacks of 
inflammation, especially if excited by some 
traumatic influence. This may not confine 
itself to the mucous membrane, but extend 
to the submucous tissues and serous coat. 
Lymph is thrown out over its neighboring 
structure and adhesions are formed, encapsu- 
lating the original seat of disease, the ap- 
pendix, and surrounding it by a barrier 
intended by nature to protect the general 
peritoneal cavity, should ulceration and per- 
foration result in the appendix. An abscess 
now forming would, contrary to olden teach- 
ings, be intra-peritoneal, though not commu- 
nicating with the general peritoneal cavity ; 
loops of intestines glued together may form 
the abscess wall and prevent general septic 
peritonitis and death. The mass often felt in 
the right iliac fossa is nothing else than this 
exudation surrounding the diseased appendix 
which may have become organized into a 
distinct abscess wall. When inflammation 
and perforation come on suddenly and before 
nature has time to protect the general peri- 
toneal cavity by such a provisional lymph- 
barrier, a violent septic peritonitis is the 
result, with death in two or three days. The 
autopsy of such a* case I witnessed three or 
four months ago. The subject was a young, 
vigorous man who was taken severely sick 
with peritonitis and died at the end of the 
third day. The whole abdominal cavity was 
in the condition of septic inflammation ; the 
appendix was perforated and sloughing, con- 
taining a cherry pit, and the caecum almost 
gangrenous and also perforated. In such 
cases there generally have been previous 
attacks of appendicitis, though in this in- 
stance no history of such could be obtained. 



January 30, 1892. 



Communications. 



175 



If an abscess has formed the pus may 
find its way under the abdominal walls or 
into the retro-peritoneal tissues, or it may rup- 
ture into the general peritoneal cavity, or into 
im intestine. Witliin three months I liave 
seen two cases with rupture into the boAvel. 
In one, a boy of 16 years, the only thing he 
complained of when he consulted me was 
inability to walk on account of stiffness and 
contraction of the flexor muscles of the 
thigli. An examination revealed a deeply 
seated mass in the right iliac fossa, tender 
on pressure. As this mass, in spite of rest 
and appropriate treatment, increased in size, 
it was decided to operate. On the morning 
of the day set for operation he had a num- 
ber of stools containing evidences of pus, 
and the mass had almost disappeared. The 
other case had two attacks of appendicitis 
withhi Jihree months, during the second of 
^vhich the abscess ruptured into the bowel. 
In both this accident was followed by rapid 
recovery. 

The disease may produce no symptoms 
outside of those of an ordinary indigestion, 
so long as it is confined to the mucous sur- 
face of the appendix. Severe symptoms 
point to a more violent inflammation not 
confined to the appendix alone. Such cases 
may be ushered in by vomiting, and some- 
times purging, accompanied with severe 
pains, particularly in the ilio-c^ecal region ; 
the pulse is accelerated, temperature often 
high, face anxious. On pressure we find 
tenderness over the seat of the disease, the 
abdominal muscles over the region are tense 
and rigid. Tympanites may supervene. 
These symptoms may continue three or four 
days and then gradually subside. In many 
cases a tumor can be felt in the region of 
the appendix. If these symptoms continue 
unabated beyond the third or fourth day, 
especially if tympanites increase, the pains 
remain severe, the pulse becomes acceler- 
ated, the temperature rises to 102° or 103°, 
perforation and formation of abscess may be 
looked for. Cases beginning with violent 
symptoms, intense pain, severe vomiting, 
marked tympanites, great tenderness in the 
ilio-csecal region, which rapidly spreads over 
the whole abdomen, rapid pulse, are of the 
gravest nature and denote perforation into 
the general peritoneal cavity. A pulse of 
over 120, with rapid breathing, slight cya- 
nosis, are extremely bad prognostic symp- 
toms, as they are the expression of toxic 
effect on the action of the heart. 

Frequently appendicitis does not have a 
typical course, and its diagnosis may be very 
difficult. The pain may be referred to other 



parts of the abdomen, the caecum being such 
a movable organ that displacement and 
change of position is not infrequent. Then 
again it may be disguised by other symp- 
toms or comjolications, such as strangula- 
tion or obstruction of the bowels. Ransohoff 
reports twelve cases in which appendicitis 
ran its course without any other symptoms 
than those of internal strangulation of the 
boAvels. Hartly also reports two cases in 
which an operation was performed for inter- 
nal strangulation, which proved to be intes- 
tinal obstruction from adhesions to the wall 
of an abscess formed by a gangrenous ap- 
pendix. It would, tlierefore, be well in all 
obscure acute cases of abdominal troubles to 
keep in mind how frequently appendicitis 
bears a causative relation to many of these 
acute afiections of the peritoneum. In ob- 
scure cases " McBurney's point " may be of 
some diagnostic value. In McBurney's ex- 
perience in every case " the seat of greatest 
pain, determined by the jjressure of one fin- 
ger, has been exactly between an inch and a 
half and two inches from the anterior super- 
ior spinous process of the ilium on a straight 
line drawn from the process to the umbilicus. 
This point indicates the base of the appen- 
dix where it arises from the caecum, but does 
not demonstrate that its chief point of dis- 
ease is there." 

The large majority of cases of appendicitis 
recover. Statistics in regard to the mor- 
tality of the disease differ greatly, however. 
It is a remarkable fact that German statis- 
tics show a much more favorable prognosis 
than those of America. Dr. Fred Lange, of 
New York, thinks that either appendicitis 
in America is more fatal than in Germany, 
or else the very severe cases in that country 
do not go to the hospitals, from which such 
statistics are derived. He says " Americans 
eat much, particularly concentrated food, 
masticate very little, and suffer from consti- 
pation," and are, therefore, particularly lia- 
ble to this disease. Renvers treated at the 
University Clinic in Berlin, within four 
years, fifty-four cases, of which three died. 
It is also stated that out of 2,000 cases of 
inflammatory conditions in the right iliac 
fossa in the German army, 96 per cent, re- 
covered without operation. Nothnagel 
treated at his clinic in Vienna from 1882 to 
1890, 65 cases — 55 men and 10 women, 
two-thirds of them between the ages of 11 
and 30 years, with a mortality of three. 
Matterstock, however, gives, out of 177 cases, 
30 per cent, mortality, of 70 children under 
15 years, 70 per cent. Fitz, in the " Trans- 
actions of the Association of American 



1-6 



Communications. 



Vol. Ixvi 



Physicians," states that he observed 72 cases, 
of which 74 per cent, recovered and 26 per 
cent. died. 

Simple cases of catarrhal appendicitis 
usually make a speedy recovery under treat- 
ment by absolute rest in bed, restricted diet, 
laxatives, particularly calomel or the 
salines, morphine, hypodermatic ally if abso- 
utely required for pain, hot fomentations 
and possibly leeches. It is the severe forms 
that give the physician greatest anxiety and 
tax his skill to the utmost. The greatest 
difficulty is to decide when to interfere 
surgically. Unfortunately, the symptoms are 
only too often unreliable guides ; often when 
the s™ptoms indicate the necessity for opera- 
tion the patient has ah-eady passed beyond 
the hope of rehef. 

Lems A. Stimson says : " We have no 
means of disting^uishino; those cases which ^\ill 
go on to the formation of an abscess without 
accident from those in which evolution 
^^ill be gravely interrupted." He, therefore, 
recommends early laparotomy (within the 
first three days), as it enables us to avert 
the process by the removal of the cause, and 
regards it as less dangerous than the ex- 
pectant treatment. McBurney states : " The 
pathological condition of the appendix as 
compared with the symptoms in my own 
cases most positively show that one cannot 
with accuracy determine from the symptoms 
the extent and severity of the disease." 
Mynter says : " That we are utterly unable to 
judge correctly from the symptoms alone of 
the extent and se^Trity of the appendix 
lesions and for this reason alone abdominal 
section must be the safest method of treat- 
ment." I believe that the advice of Thos. B. E. 
]\Iorton, who, in connection mth his lather, 
Thos. G. Morton, has devoted considerable 
attention to this disease, and whose expe- 
rience in the surgical treatment of this 
disease has been quite extensive, is not only 
good, but sufficiently conservative to meet 
the approval of the non-operative physician. 
It is, "to operate not later than the third 
day of the disease, if the patient up to that 
time has failed to markedly improve, under 
rest, restricted diet, ]3urgation and topical 
applications. Especially should this rule be 
adhered to in cases where we have failed to 
move the bowels — ^they are apt to be of the 
fatal cases. Further than this we should 
invariably operate as soon as the presence 
of pus is assured ; when peritonitis is de- 
veloping and spreading ; when signs of sud- 
den rupture of an abscess into the peritoneal 
cavity appear, and w^hen septicaemia from 
septic absorption is taking place. In 



children operation must often be done earlier 
than in adults, as in them the malady is 
more speedy in development, more fatal in 
tendency and shows greater prochvity to in- 
volve the general peritoneal ca^^ty." ( Thos. 
S. E. Morton, Philadelphia Countv Societv, 
Sept. 28, 1891.) 

Pelvic peritonitis is the most common 
form of peritoneal inflammation in the female. 
It is most frequently localized A\ith a ten- 
dency to remain so. and follows an essen- 
tially chronic course, with occasional acute 
exacerbations. ]\Iore so even than appen- 
dicitis is it characterized by frequent 
relapses. One-third of all| gynecological 
cases are victims of this disease. Bande 
found residue of circumscribed peritonitis 
in more than half of all female cadavers, 
Winkel in more than 33 per cent., A. 
Martin in 122 out of 287 cases of tubal 
disease. 

The cause of pelvic peritonitis or peri- 
metritis, as it is also called, in a large 
majority of cases, is diseased tubes. This 
is a fact which has only been learned quite 
recently. ]Most inflammatory conditions in 
the pehds were thought to originate in the 
cellular tissue, and from there sometimes to 
invade the peritoneimi ; celluhtis was, there- 
fore, the primary and most important 
disease. Not later than six years ago, 
Emmet, in the last edition of his work on 
Diseases of Women, says : " I shall employ 
the term *' celluhtis ' in expressing the most 
common condition of pelvic inflammation in 
connection with non-puerperal diseases of 
women. Pelvic peritonitis will not be treated 
of as a distinct lesion, but as an accident, 
rendering the case of cellulitis more grave in 
character from this Cviniplication." The first 
description of the true pathology of peh^c 
inflammation was given us by Bernutz and 
Goupil, over thirt\' years ago, who, by a 
careful e-xamination of ninety-nine cases, 
both during hfe and m the post-mortem 
room, pointed out very clearly that it was not 
the cellular tissue which was involved in this 
inflammation, but the peritoneum and that 
the cause of it originated m the fallopian 
tubes. Their teaching, however, was entirely 
ignored until operative surgery has opened 
up the peritoneal cavit}' to daily explora- 
tions and found the conditions exactly as 
described by these investigators. The 
masses and indurations generally found in 
the pelvis by bi-manual examinations and 
spoken of as exudations in the pelvic 
cellular tissue can be removed by the sur- 
geon from the peritoneal ca^^ity ; they do not 
involve the cellular tissue to any extent, 



January 30, 1892. 



Com muni c a tions. 



177 



but consist of ovaries and tubes folded upon 
themselves, matted together by exudation 
and adherent to the posterior surface of the 
broad ligament of the uterus. Frequently 
we find also intestines and omentum or an 
appendix as a part of the tumor. Polk, in 
1886, in a paper on the "study of sixteen 
cases of so-called pelvic inflammation, known 
as ' pelvic cellulitis,' " states that abdominal 
section was made in all these cases and the 
lesions found were salpingitis, peri-ovaritis 
and pelvic i^teritonitis. In two of ten cases 
there was slight (edematous swelling of the 
cellular tissue in the broad ligaments, just 
beneath the spot at which, an inflamed tube 
had rested ; in the remainder the most care- 
ful examination failed to detect the slightest 
induration or swelling in any part of the 
cellular tissue that lay about the uterus 
or between the layers of the broad liga- 
ments. 

Dr. N. C. Coe (Exaggerated Importance of 
Minor Pelvic Inflammations) says: "Of half a 
dozen fatal cases of hysterotrachelorrhaphy 
and incision of the cervix in which I enjoyed 
the rare opportunity of studying carefully the 
sequence, in every instance the cause of death 
Avas acute difHise peritonitis." In regard to 
the more chronic cases to w^hich circum- 
scribed areas of inflammatory exudations 
Avere found, he states that " peritonitis is cer- 
tainly the most prominent element in most of 
these cases, so far as the post-mortem appear- 
ances afford any light ;" and again, " By far 
the greatest number of these indurations are 
situated high up in the broad ligaments and 
consist of cicatricial masses, mostly confined 
to the peritoneum of tubes and ovaries sur- 
rounded by old adhesions, or occasionally an 
imprisoned knuckle of intestine. I confess 
that I have rarely (perhaps half a dozen 
times) found such thickenmg in the cadaver 
which could be inferred to a pure and 
straightforward cellulitis, and this, too, when 
I have recognized by the vagmal touch (be- 
fore and after death) what seemed to be an 
induration, a distinct band extending outward 
from a deep laceration of the cervix, or a 
condition of tension in or above one lateral 
cul-de-sac, which did not exist on the opposite 
side." 

Joseph Price, who has been in the abdomi- 
nal cavity oftener than any other American 
surgeon, says : " The operative g3^n8ecologist 
does not find any pelvic cellulitis." Lawson 
Tait is equally emphatic on this subject. 

Having established that celluhtis is a rare 
disease, at least outside of the puerperium, 
and that what we used to regard as such is in 
reality, in the large majority of cases, a. pel- 



vic peritonitis from the outset, we Avill now 
briefly inquire into the etiology of the latter. 
A diseased tube is usually the focus from 
which the peritoneal infection starts. Disease 
of the appendages may have preceded the 
attack of peritonitis for weeks or months 
when a leaky tube may precipitate a peri- 
tonitis, that is, the secretion pent up in the 
tube may discharge through the abdominal 
orifice of the tube into the peritoneal cavity, as 
the result of hyperdistension, trauma, violent 
exertion, etc. Or the tubal disease may arise 
acutely, and extend at once to the perito- 
neum, the most common causes in producing 
inflammation of the uterine adnexa puerpual 
infection, gonorrhoea, extension of an en- 
domitritis to the tubal mucous membrane, a 
catching cold, especially during menstruation, 
etc. Unskillful intra-uterine treatment, minor 
operations about the cervix, such as Emmet's 
operation, dilatation, etc, especially if done 
without the strictest antiseptic precautions, 
are frequently followed by salpingitis and 
subsequently peritonitis ; the introduction of 
an unclean sound, especially if it produce a 
lesion to the mucous or muscular surface of 
the uterus frequently results in pelvic in- 
flammation. The symptoms of pelvic peri- 
tonitis vary considerably in intensity. While 
often so mild as to escape our attention, its on- 
set may, especially if due to a leaky pus-tube, 
be so sudden, severe, and violent as to resem- 
ble a peritonitis following perforation. The 
disease is usually ushered in by a chill, fever, 
more or less severe pains in the lower part of 
the abdomen, back, and thighs ; irritability^of 
the bladder, sometimes rectal tenesmus. The 
hypogastric region is tender on pressure and 
vaginal examination very painful. Within 
forty-eight hours a swelling may be noticed 
on bi-manual examination, which, in a few 
days, may reach to the umbilicus. It is, at 
first, soft, baggy, almost fluctuating, but grad- 
ually becomes firmer until it often appears as^ 
hard as a board. 

Under rest, opiates to relieve suffering, hot 
fomentations, and, after the febrile symptoms 
have subsided, the iodides, internally, and 
tonics, and the local application of iodine 
over the abdomen and to the vaginal vault,, 
hot douches, glycerine tampons, iodoform^ 
ichthyol, etc., the exudation gradually de- 
creases, until after a few weeks or months it 
has become imperceptible. The patient's ap- 
petite has improved, her pains have lessened 
or disappeared entirely, she is gaining flesh, 
and regards herself as cured. The inflamma- 
tion, how^ever, does not always run such a 
smooth course. Instead of ending in resolu- 
tion it may go on to suppuration. Abscesses 



178 



Communications. 



\'o\. xlvl 



form and may discharge through yagina, rec- 
tum, bladder, abdominal walls, or intestines. 
They may then heal spontaneously, yery 
rapidly, or they may continue to discharge 
indefinitely, until the patient dies from exhaus- 
tion or sepsis, unless surgical measures are 
adopted. Eyen if the disease ends in resolu- 
tion, this does not alyavs mean cure. On 
the contrary, it is often followed by a life of 
misery and suffering. When the patient re- 
turns to her ordinary duties she iinds she is 
unable to fulfill them. She has achmg in her 
back, abdominal pains, increased on slight 
exertion, disturbance of her gastric functions, 
and other reflex symptoms. Her menses are 
more profuse than formerly and more painful, 
marital relations are accompanied "srith suffer- 
ing or may haye become utterly unbearable ; 
in that she presents the picture only too 
familiar to eyery physician practicing in 
g;)Ti8ecology. Examination reveals extreme 
tenderness oyer one or both uterine adnexa ; 
perhaps some thickening in the region of tube 
and ovary, or you may find large masses in 
the region of tube and ovary and filling up 
Douglas' pouch. In other words, while all 
active peritoneal inflammation may have 
subsided, the focus of the disease, the dis- 
eased appendages have remamed and wait 
only a favorable opportunity to light up an- 
other acute pelvic peritonitis. I have seen 
thi'ee and four such attacks Y\ ithui one year. 
Such cases mil probably go on from bad to 
worse until these diseased appendages are re- 
moved. 

For the sake of convenience the results of 
pelvic inflammation may be tabulated in five 
groups. 

1. Complete resolution and recovery. 
Such cases are restored to perfect health and 
are able to bear children. 

2. Adhesions al^out ovaries and tubes 
which, however, do not affect the general 
health of the patient, but are frequently asso- 
ciated with sterility. 

3. Recovery with a catarrhal salpingitis 
and possibly oophoritis, which, under proper 
but often prolonged treatment, improve and 
often get perfectly well. 

4. Includes cases of old and obstinate forms 
of • salpingitis, hydrosalpinx and oophoritis, 
who pass from one physician to another, or 
from one quack to another, and are doomed 
to permanent invalidism, unless relieved by 
the removal of the diseased organs. 

5. And last are principally the victims of 
grave puer]^)eral affection or gonorrhoea, suffer- 
ing from pyosalpinx and ovarian abscess, 
which are certainly threatening their lives 
and are only curable l)y laparotomy. 



In concluding this rather lengthy paper I 
make no claims to originahty or thoroughness 
in tf eating this important subject. I am well 
aware that it is merely a fragmentary exposi- 
tion of the subject presented. ]Many points 
that seemed of particular importance to me 
have been dealt upon rather in detail, while 
others, undoubtedly appearing equally or moi-e 
important to some of you, I have only touched 
upon. Any omissions in this pa}>er will, 
mthout doubt, be supj^lied in the discussion, 
which, I ho2>e, will be full and exhaustive. 
{For discussion, see Society Beporfs.') 



GUMMA OF THE IRIS. 



By FLOREXCE MAYS. M. D., 

PHII.ADELPHIA. 



Tln-ough the courtesy of Dr. Edward 
Jackson. Surgeon to Will's Eye Hospital, I 
report the foilo^ving case, which is of interest, 
combining as it does so many ocular conditions, 
the results of s^-i^hilis. viz., iritis gumma of 
iris, hypopyon, keratitis punctata and papil- 
litis : * 

F. C , aged 19 years, came to Dr. 

Jackson's Clinic, Will's Eye Hospital, June 
27, 1891, saying that his left eye had been 
inflamed and painful for three weeks. His 
rigiit eye had beeri sore one month before. 
The following specific history Avas elicited : He 
had had an initial lesion six months before, one 
month after exposure. The secondarv svmi> 
toms, such as glandular enlargements and 
mucous patches of mouth and fauces fol- 
lowed. At this time the patient was suffering 
from acute coryza. Said that he caught cold 
one week before. As he had been" taking 
no medicine the coryza could not be attri- 
buted to the effect of potassium iodide. 

O. D. Sub-acute hyperiemia of reflected 
and tarcal conjunctiva. Puj^il, 4 mm. m di- 
ameter and normal. Globe, normal. A" = 4. 

O. S. Intense inflammation of tarsal and 
reflected conjunctiva, extending up to cornea 
Arith marked ]3ericorneal zone. Moderate- 
sized ulcer on conjunctiva between inner 
canthus and cornea. Cornea hazy. Anterior 
chamber deepened ^rith hypojjyon below. A 
yelloAnsh gumma 6x4 mm. in diameter. 
^vith. vessels upon it, upon the nj^per nasal 
quadrant of iris. Gumma somewhat mder 
than iris and extending well forward. Pupil 
irregularly oval, long axis 30°. Iris yellowish- 
green. Iris of O. D., gray hazle. V= lyer- 
ception of mo™g fingers four inclies fi-om 
the eye. 

Ophthalmoscopic examination : O. D. 
Low H. Disc reddened and swollen. Disc 



January 30, 1892. Society Reports, 



179 



margins almost entirely obscured. Arterial 
sheaths marked beyond disc. 

O. S. Very indistinct fundus reflex. Punc- 
tate opacities marked in lower part of 
cornea. 

The patient was ordered calomel gr. \ t.d. 
by the mouth, and one drop of four grain 
solution of sulphate of atropine in O. S. t.d. 
He was also directed to use hot compresses. 

Five days later, J uly 2, the patient re- 
turned improved and was given protiodide 
of mercury, gr. \ t. d., in place of the 
calomel, and told to gradually increase the 
dose. 

July 7, he was much improved, and was 
given a solution of sulphate of hyoscyamine 
for the purpose of determining the refraction 
of O. D. 

July 9. C. Hyos. O. D. V = 4 + 0.50 
D. Sph O + 0.25 cy. ax. 90° = \, 

July 16. Patient was taking five grains of 
protiodide of mercury daily. Gumma en- 
tii-ely absorbed. Coloboma of iris at former 
seat of gumma. Pupil key-hole and semi- 
dilated. Pericorneal zone still present. 

The patient ceased to visit the clinic at 
this time, so no further opportunity for the 
study of the case was afforded. 

414 W. Huntingdon St. 



THE ACTION OF ORBXIN ON THE 
STOMACH. 

Dr. W. Brunner, in Gazette Lekarska, 
March 14, 1891, gives his experience with 
the use of orexin and its action upon the stom- 
ach. 

His experiments were made upon thirty 
persons (180 separate observations). The 
doses employed were 0.25 to 0.30 gramme, in 
pills or capsules, two or three times daily. 

In four healthy persons pain in the epi- 
gastrimes and vomiting appeared after the 
second dose was taken. 

In tw^elve neurasthenic and hysterical pa- 
tients, with impaired mechanical action of 
the stomach, the appetite was increased in 
six ; this did not last long, for upon stopping 
the use of the drug, the appetite became 
poorer than before, with pain in the stomach 
and severe ringing in the ears. In another 
group of ten cases (patients with consump- 
tion, rheumatism, and cardiac disease) the 
effect was also doubtful. In four cases of 
gastric diseases (one catarrh, two cancer, and 
one dilatation) the pain and vomiting were 
aggravated. 

In view of these experiments, the author 
recommends that orexin be dropped entirely 
from the list of reliable medicinal remedies. 



SOCIETY REPORTS. 

ALLEGHENY COUNTY MEDICAL 
SOCIETY. 



J. J. Green, M. D., President pro tem., in 
THE Chair. 



Scientific Meeting, November 17, 1891. 



Dr. X. O. Werder read a paper on Peri- 
tonitis. (See page 173). 

Dr. Baten : I do not think I can say 
anything new on the subject. The disease, 
however, is not so old as the reader Avould 
lead us to believe. The Italian physicians 
in the latter part of the seventeenth and the 
beginning of the eighteenth century w^ere the 
first who gave some of the symptoms of the 
disease. They studied the disease and made 
the diagnosis of peritonitis. Cullen, in 
1775, mentions the disease, but does not de- 
scribe it. Gast said in 1809 that the sjnnp- 
toms of the disease had been truly known 
for only twenty years, so that we did 
not have a true history of peritonitis until 
1789. 

I have had two cases of the disease which 
he describes, that is, I suppose it would be 
classed mider that disease, pelvic peritonitis. 
It requires a good deal of time to make out 
the disease. I remember in these two cases 
I attended — and I had a good diagnostician 
to see the cases with me — we were unable 
to make out the disease until nearly the end 
of the second or third week. One case, how- 
ever, went on, and an abscess was formed 
and opened, and the j)us let out and the pa- 
tient recovered. In regard to the existence 
of these diseases, I have no doubt they ex- 
ist a great deal more frequently than we 
have any idea of or even suspect, and a great 
many patients likely go on without any 
treatment whatever, or any successful treat- 
ment, and remain as invalids the remainder 
of their lives, if they do not come in contact 
with some one who can make out a proper 
diagnosis. 

Dr. Macfarlane : I listened with a great 
deal of pleasure to the doctor's paper. Whilst 
septic peritonitis is more common than the 
majority of the profession appreciate, possi- 
bly owing to inability to diagnose it, I think 
very many medical men recognize trouble 
about the appendix, even though no tumor 
can be found in the region. I think some- 
times the trouble is referred to the appendix, 
mistakenly. Still the matter is, of course 



i8o 



Society Repo7^ts. 



Vol. Ixvi 



more or less common. About the location 
of the appendix, by the aid of McBurney's 
point, it was my pleasure to read quite a 
lengthy discussion upon the matter. It 
was pointed out by an anatmoist that the 
base of the appendix rotates upon two or three 
planes and never upon one point. Although 
I believe it does nothing more, McBurney's 
point will serve a purpose in attracting atten- 
tion to the region more than has been done 
heretofore. I think the teaching of older med- 
ical men had a good deal to do with the 
mortality in these cases, for the very reason 
that they were thoroughly imbued with the 
idea that when you have disease of the intes- 
tine you are to place the intestine in a splint 
with opium, and while the patient is relieved 
from pain the mischief is going on there in 
spite of the opium. While laxatives may be 
abused, I think that very frequently, espe- 
cially by the use of calomel, good could be done 
mth them at the outset, and very many cases 
are cured with the use of purgatives and hot 
applications and rest in bed, whilst if the 
opium treatment is continued to any excess, 
just what you want to avoid, that is, the ac- 
cumulation of fecal matter in and around 
the parts, will result disastrously. 

Dr. Buchanan : One or two points I think 
might be dwelt on a httle more at length than 
has been done this evening. I suppose it 
would be right to confine the discussion to the 
matter which has been presented by the gen- 
tleman who opened the discussion — the sub- 
ject of appendicitis and peMc peritonitis. 
These two subjects illustrate the advance 
which the gynaecologist has made in medicine. 
On the subject of appendicitis all medical 
men are pretty well versed ; they do not re- 
quire the services of a specialist to give them 
any information ; Avhereas, when they come 
to examine the ovaries and tubes, many other- 
wise well-informed practitioners are all at sea. 
It is because they are not accustomed to the 
bi-manual method of examination ; they are. 
not in the habit of taking these parts between 
their fingers and finding out what they hold. 
In most cases of pericecal abscess operation is 
readily acceded to, while in many ovarian and 
tubal abscesses they frequently object to the 
opening of the abdomen for the removal of 
these abscesses, because they have no famili- 
arity ^\ith the examinations necessary to de- 
monstrate the condition. 

In inflammation of the appendix, I believe 
that wherever there is a tumor to be demon- 
strated,!there is always localized peritonitis and 
the cases can be grouped into three classes : 

First, those in which the inflammatory col- 
lection is such as to give rise to a tumor 



which can be felt, and Avhich goes on to reso- 
lution. These are the great majority of cases, 
and for that reason alone I think it would be 
unydse to treat aU cases by abdominal section. 
Statistics given are to the effect that a very 
large percentage of cases get well with merely 
palliative treatment. 

The second class of cases includes those in 
which the peritonitis goes on to the forma- 
tion of a locahzed abscess. This abscess 
sometimes opens spontaneously, occasionally 
through the bowels ; when an incision is re- 
quired, it is often merely the opening of an 
abscess, the peritoneal canity not being in- 
vaded. 

The third class of cases comprises those 
where no local abscess is formed, but where 
the first peritonitis is a general peritonitis, 
and these are the unfortunate or fatal cases 
that Dr. AVerder has spoken of, and he gives 
a reason for the diflTerence ; for one bemg lo- 
cahzed and the other generahzed peritonitis. 
The peritonitis has not had time to shut ofl" 
the disturbing element and encapsidate it in 
an abscess. I mil make a suggestion in these 
cases. It is not the element of time that 
makes the difierence, but the nature of the 
material that excites the peritonitis. A j)er- 
foration may be made and no streptococci or 
other A^rulent germs may have entered. In 
this case it is a non-septic peritonitis, there- 
fore a local peritonitis ; for the same reason 
that, in cases of gonorrhoeal salpingitis, at- 
tacks of local peritonitis are common. The 
gonococcus may enter the peritoneal cavity, 
and it has been pretty well established that 
when it does enter that cavity it is not an 
extremely dangerous v isitor. It sets up a 
locahzed peritonitis, and these are the attacks 
of locahzed peritonitis that prostitutes have. 
Entirely difierent is the course of the peri- 
tonitis which aiises from the bursting of an 
abscess, the, result of infection at the time of 
confinement. Here the most ^drulent germs 
enter the cavity and give rise to a general 
peritonitis which may result fataUy in a few 
days, possibly in a few hours. As I said be- 
fore, the difierent coui'se of the peritonitis in 
second and third stages of appendicitis, may 
not be due to the element of tune, but it may 
be in the nature of the exciting cause of the 
peritonitis. 

Now the subject of inflammation of the 
fallopian tubes which frequently gives rise 
to what is commonly recognized as pelvic 
peritonitis, is a subject which, I beheve, in 
this part of the country has not received 
sufficient attention. I have seen ^dthin the 
last couple of years a good many cases 
where abscesses of the ovaries and tubes 



January 30, 1892. 



Society Reports. 



181 



€ould be demonstrated easily, and where the 
operation has not been recommended to the 
patient by the attending physician, even 
though attention was strongly called to it. 
I recall one case where a patient with an 
ovarian abscess was treated for malaria by a 
gentleman who is considered in the front 
rank of the profession in this city, until the 
abscess broke through the vagina. - Now, 
that could only have come through lack of 
examination. Another case was one of gon- 
orrhoea! salpingitis, followed by very severe 
local peritonitis, in which a mass could be 
distinguished very easily after the peritonitis 
had subsided. This patient is now under 
electric treatment. Her doctor comes every 
day, or second day, and applies the battery. 
This woman has been about one and one-half 
years undergoing this and similar treatment 
and has not had a well day. Another case 
was treated by a most excellent physician in 
this city, one who stands very high, which I 
never saw but once and then at his request. 
This patient had probably an abscess, cer- 
tainly as large as my fist. This woman had 
been carrying this abscess, according to ac- 
counts, for about three years. She was an 
invalid as most of these cases are. It was 
pitiable to see her turn in bed. This gentle- 
man had not advised or apparently thought 
of an operation. He was much pleased at 
her being a little better than she was a month 
before. Another case I saw about a year 
ago in a neighboring town. She had an ab- 
scess that could be distinctly felt by any per- 
son who put his hand on the abdomen. This 
patient had been constantly in bed for two 
years, and in that time had not touched her 
feet on the floor. She has since died. I 
mention these cases because I believe that 
many others of similar character now exist 
in this and neighboring communities, and 
that this matter is not sufliciently talked of 
by the profession here. 

Dr. Lange : The subject of peritonitis 
has been limited to pelvic peritonitis and ap- 
pendicitis. I am at Avork at the present time 
upon a paper reporting a series of twelve 
cases of typhlitis, part of the number that I 
have treated during my professional life, and 
of which I have accurate and ftill notes. I 
will publish these cases as I complete them. 
I must state I have never lost a case of 
typhlitis. I stand with the Germans in this 
respect, if, as the reader of this paper stated, 
the molality in Germany is very much 
lighter than in America. Of these twelve 
cases of which I have notes, one only re- 
ceived surgical treatment, and that was a 
simple incision through the bell-wall for the 



evacuation of pus. Dr. Werder seems to 
support the statement that after a duration 
of three days, the inflammation — typhlitis — 
not showing any apparent improvement, a 
section would be indicated. It strikes me 
that this is entirely too energetic, that it is, 
to say the least, unwarranted. This is all 
right when pus has been demonstrated. Other- 
wise it is not warranted, because we still 
sometimes have septic peritonitis after ab- 
dominal section with the most careftil precau- 
tion by the most careful operator. In other 
words, antisepsis is not yet thoroughly un- 
derstood nor mastered. As long as this is 
true, it is unwarranted to advocate incision 
in typhlitis because it does not improve 
after an existence of three days. The reason 
is not sufiicient. It must still be the dem- 
onstration of pus. It is justifiable, how- 
ever, to dilate the sphincters, enter the hand 
into the rectum and search for pus, because 
it forms frequently behind the caecum, and 
when so, cannot be found by examination 
through the belly-wall. 

Among the twelve cases I shall report is 
one in which the tumor was as large as a 
melon, where, upon careful and repeated ex- 
aminations, no pus could ever be found. A 
deformity lasting almost two months after 
recovery existed by reason of extreme flexion 
of the thigh upon the abdomen during the 
inflammation, and the whole limb was infil- 
trated and (Edematous from vein-pressure, and 
before the leg could be brought down and the 
tiunor disappeared, had a duration of between 
three and four months. The recovery is per- 
fect. I think I have a right to assume that 
no pus existed in that case, and I would, with 
aU due regard for the opinion of the authority 
quoted by Dr. Werder and of Dr. Werder 
himself, insist that this rule is unjustifiable. 
The criterion, I think, must be the demonstra- 
tion of the existence of pus. The treatment 
of general peritonitis has undergone some 
change. The change advocated in the last 
few years is the administration of purgatives, 
particularly the sulphate of magnesium in- 
stead of opium. I believe that general septic 
peritonitis is always fatal, and I beheve we 
often speak of general septic peritonitis where 
it does not exist, as for instance : I was re- 
cently concerned in a case Avhere an abdomi- 
nal section was done, and on the third day it 
was concluded that the patient had general 
septic peritonitis. She was given, at my ear- 
nest solicitation, morphine. The sulphate of 
magnesium treatment was ruled out by my 
insistance, and she recovered. I was doubt- 
ful of it at the time, and now I do not believe 
she had septic peritonitis. One case of septic 



l82 



Society Reports. 



Vol. Ixvi 



peritonitis I remember very distinctly, oc- 
curred five or six years ago. A patient came 
to my office in the middle of the night out 
of breath, said his neighbor was very sick, 
and took me to his bedside. I went with this 
man for a distance of three blocks, and found 
the patient with an extremely bad case of 
cholera morbus. I gave him morphine, re- 
mained with him about half an hour, and 
when he was better, the mfe of the messenger 
came to me, and said : " Doctor, my husband 
has the same thing." I went mto the adjoin- 
ing house, and found this patient with ap- 
parently a very severe attack of cholera 
morbus ; but it was septic general peritonitis, 
and killed him in forty-eight hours. Here 
Avere two cases occurring at the same time 
and side by side, and, though I may lack 
special acuteness, I could see no difierence 
between them. It was impossible for me to 
say that one had a certainly fatal affection 
and the other a temporary slight illness with- 
out any mortahty. This was true until the 
effects of morphine decided one to be cholera 
morbus. Both were chilled, both Avere 
shocked, both Avere \^ery tender and t3mipani- 
tic, both drcAV up their legs, both Avere cold 
and blue and almost pulseless, and both had 
death m their faces. Both also A^omited and 
purged, and both Avere CAudently in unutter- 
able anguish. I could appreciate no differ- 
ence betAA^een them. From this and like evi- 
dence, I believe a diagnosis of general septic 
peritonitis is not ahvays correct ; and further, 
that Avhen such a patient has recoA^ered under 
the magnesium treatment, no general periton- 
itis existed. I am told by a laparotomist of 
large experience that most of his Avomen on 
the third or fourth day have such an attack ; 
that he gives them magnesium and they get 
well. But this is certainly not general septic 
peritonitis. I believe it is a colic Avith meteor- 
ism from handling or exposing the boAvels ; a 
condition analogous to that frequently seen 
after hard protracted labor, and in such cases 
the magnesium treatment is excellent. But 
in my opinion, a patient Avith septic peritonitis 
dies. There are two Avays, generally, by 
Avhich septic inflammatory agents reach the 
peritoneum : by ulceration through the 
stomach or intestinal tract, and in women 
from the genitalia. The messenger for the 
cholera morbus man probably had some ulcer 
of the boAvels, perhaps painless, Avith a per- 
foration Avhich happened through his Adolent 
run to my office that night. No jyost mortem 
Avas had. One thing that appears from Dr. 
Werder's paper and the discussion is that no 
one mentioned idiopathic peritonitis. I be- 
licA^e there is no such peritonitis. The mes- 



senger of Avhom I spoke Avas seen by other 
physicians, and the conclusion AA^as that he 
died of idiopathic peritonitis. But this was 
many years ago, and, barring puerperal and 
traumatic inflammations of the peritoneum, 
all others Avere idiopathic. We knoAV better 
noAv. As to the treatment of this septic in- 
flammation of the peritoneum, if there be- a 
chance to benefit patients, I believe it to be by 
opium, and \^ery slight. Dr. AndrcAA" Clark, 
as all the AA^orld knoAA^s, AA'as a very eminent 
physician, and he reported a number of cases 
of acute general peritonitis cured by the 
opium treatment. I do not know Avhether 
that is correct. It possibly is, but from AA-hat 
I have seen, I must doubt it. As to Avhat I 
haA^e seen of magnesium treatment in cases 
Avhere the diagnosis Avas certain, I must con- 
demn it. Can you do anything else Avhen 
you think of typhoid or duodenal or gastric 
ulcer perforation ? I belicA^e the prognosis to 
be always extremely bad, and the only forlorn 
hope to be opening the belly and AA^ashing it 
out. 

Dr. Macfarlane also objects to the opium 
treatment, to "putting the boAvels in splints " 
in perityphlitis. I have here tAA^elve cases of 
such peritoneal inflammation, all of Avhich re- 
coA^ered and all of which AA^ere so treated. I 
have had additional cases of Avhich I haA^e no 
record, Avhich Avere treated and AA^hich ended 
in the same manner. Therefore I shall 
continue so to treat them. But I do not use 
morphine alone ; I do not trust to morphine 
alone. I use also calomel. We were AA'ont to 
say for its alteratiA^e effects, noAV Ave giA^e it 
for its antiseptic and antiplastic effects. 

Dr. KcENiG : It seems to me Dr. Lange 
must haA^e misunderstood Dr. Werder in re- 
gard to at least one assertion. He said Dr. 
Werder had not mentioned idiopathic peri- 
tonitis. If I am not mistaken. Dr. Werder 
declared that peritonitis might be produced as 
a result of catching cold " at the time of the 
catamenial period. If that means an}1;hing 
else than idiopathic peritonitis, I fail to under- 
stand it. The term " catching cold," to my 
mind, is simply an admission of ignorance. I 
Avish also to add the Aveight of my testimony 
in faA^'or of the opium treatment. We want 
to relieve the nervous system of the irritation 
that the disease 23roduces, and Ave can do it 
better by opium than by any other remedy. 
The late Professor Austin Flint was some- 
times jestingly accused of having reduced his 
medication to the use of tAvo drugs, Avhisky 
and opium, and I Avell remember his remarks 
regarding opium. In serious diseases, he ad- 
mitted, it Avas not curative under the ordinary 
acceptation of that term, but he declared that 



January 30, 1892. 



Society Reports. 



it was curative nevertheless, for the reason 
that it established a tolerance of the disease 
for the time being, allowino- nature to re]>air 
the trouble under the reduced sensibility of 
the nervous system. 

Dr. Grube : I can recall two cases which I 
think illustrate the fact that no one line of 
treatment can be laid down. Each case must 
be treated on its own merits. One case was 
of peritonitis which went along for sume two 
weeks or more, until I was satisfied there was 
pus present. I demonstrated the presence of 
pus by the hypodermic needle, and tlien I 
operated. It was a very simple opera- 
tion. I riierely cut down tlirough the 
nuiscles of the abdominal wall and met the 
abscess cavity, and, instead of cutting into it, 
I took the forceps and stretched it, and the 
pus came out, and that was the extent of the 
operation. Any physician can do that. 

The next case was very much like it, and 
I thought I would liave another opportunity 
for operation, for I had some of the surgical 
enthusiasm. I watched the case, and in about 
a week the whole tiling disappeared without 
any pus at ail. ^ly idea of the treatment of 
all these cases is as Dr. Lange said. The 
time f)r operation is when you can demon- 
strate the presence of pus, and not until such 
time, with the exception of the cases where 
you have collapse, and if they are not oper- 
ated on quickly, you have no chance of 
saving your patient, ^ly own experience has 
been that each case has to be watched care- 
fully. What is necessary in the case is sim- 
ply (Opening the abscess, or else we will kill 
our patienrs very quickly. 

Dr. ^Mc KiBBOX : The gentleman on my left 
has stated the history of two cases that he 
had. Dr. Senn, of Milvraukee, has given the 
history of the cases he treated. He claims 
the operation done in this condition is practi- 
cally of very slight importance, and on the 
other hand, that by waiting for these cases to be- 
come bad is the worst treatment that can be 
pursued. He says the operation is not of 
sufficient magnitude to wait until there is 
something turning up. 

De. Buchaxax : I would like to express 
myself against making a fixed time for opera- 
tion. I think, with Dr. Lange. that to fix 
absolutely on the third day as the time to 
operate if the patient is not improving, is 
rather arbitrary. I coidd submit a number 
of cases that got well without an o}>eration. 
I have seen many cases that did badly for 
three days and eventually recovered without 
early interference. I think Dr. Lange has 
been wonderfully fortunate in the class of 
cases he has had, if he has had twelve con- 



secutive recoveries. One of his cases would 
have been much better with an operation. I 
tiunk very few of us would be willing to let 
such a mass go on, even to the size of a ^mall 
melon, without opening it up and en- 
deavoring to do away with the origin of this 
innnense intlannuatory exudate. I think- 
there was pus in this case. According to the 
history given, this patient did not make a 
very pleasing recovery. I think Dr. Grube 
has very v,-eil stated the two classes of cases 
that should be submitted to operation, those 
in which pus can be demonstrated and those 
in which tlie perforation, is through the ap- 
pendix, and is setting up general peritonitis. 
If you can catcli such cases in time, it is 
proper to remove the appendix and wash out 
the cavity. Usuallv they die. 

Xow, in re])ard to septic peritonitis. 
As I understand Dr. Lange, he makes the 
test of se})tic peritonitis tlie death of the 
patient. If he dies it Avas septic peritonitis, 
and if 'le recovers it was not septic periton- 
itis. I do not think this a fair way to test 
the method of treatment for that disease. 
If I liavl septic peritonitis, I would like to 
have some very vigorous treatnieut with ep- 
>(>m >alt> at first, and if that did not suc- 
ceed very soon, I would be willing to take 
very large doses of opium. 

The case which has been cited, in which 
marked unprovement took place, which was 
suj)p(^sed at first to be septic peritonitis and 
recovery (occurred in three days, it seems to 
me, from the description of the symptoms, 
was one of beginning septic peritonitis. I 
think very likely if the operations of this 
gentlemen were all followed on the third or 
fourth day by the symptoms described by 
Dr. Lange, it was the result of septic condi- 
tions. It has been remarked that Dr. Sands 
ahvays advocated the removal of the appen- 
dix. This is certainly proper in case you 
can find it, but you can not always get it. It 
is a nice thing to remove and a safe thing to 
remove ; at the same time I do not think it is 
a very good thing to hunt for it. There is a 
great deal of change taking place in the sur- 
rounding parts which render it difficult to 
find. The rule that operations should be 
made parallel ^^■ith and a short distance above 
Poupart's ligament is a very good rule, ex- 
cept in those cases where the abscess does 
not approach the ligament. There is a class 
of cases where the localized peritonitis 
occurs opposite the umbilicus or a little 
lower. 

De. Laxge : I do not set myself up as a 
judge concerning the case Dr. Buchanan has 
reference to, but merely submit my opinion. 



i84 



Society Reports, 



Vol. Ixvi 



I think the doctor will agree with me that 
if my associate in the case was correct when 
he said that nearly all his patients had such 
symptoms on the third or fourth day, that it 
was not septic peritonitis, because if all his 
j)atients had septic peritonitis and all got 
well, that gives a grand and new aspect to 
the whole matter. I did not believe at the 
time that it was septic peritonitis ; re- 
covery confirms that belief. I am entirely 
willing to put myself on record that when 
this inflammation does not kill, it is not 
septic and not general ; in other words, that 
septic general peritonitis is fatal, despite 
o^^ium, calomel, magnesium, or any drug that 
miiy be given ; that wlien such a case ends 
in recover}^ it involves an error of diagnosis. 
Another point, the operation of opening an 
abscess, which I did in one of my twelve 
cases, is quite a different thing from opening 
the cavity on the third day of perityphlitis. 
There may be no pus-sac, no j)us cavity ; 
if not you will get into the general peritoneal 
C-ivity, easy enough in any event ; if you do 
not, if you content yourself with cutting 
down to the tumor adherent all around, and 
do not free it, and palpate and examine it, 
3^ou have accomplished nothing. Doing this 
thoroughly, all the chances are you Avill get 
i 1 ; and if you do not, and there is no pus, 
what have you accomplished ? Nothing. 
The criterion still must be, pus or no 
pus. 

Dr. Greek : I want to say one word in 
regard to trying to make the distinction be- 
tween septic and non-septic peritonitis. It 
seems to me in nearly all cases it can be de- 
tected by the general symptoms of the patient. 
I think the best guide is the condition of the 
patient. That is the general condition, and 
the general aspect of the patient. If the 
disease is of a bad nature, the patient will 
readily succumb. These are the symptoms 
I have allowed to guide me in all such cases, 
and I think no physician ought to find any 
trouble in distinguishing, after twent^^-four 
hours, what kind of a case of peritonitis he 
is dealing with. I think twenty-four hours 
Avill determine the case, thirty-six hours at the 
utmost. 

Dr. Werder : I am thankful for your 
kind consideration of my paper and also for 
t]ie discussion of the subject. I have very 
few remarks to make, because the matter has 
been discussed so thorouglily that there is 
not much to be said. Only a few points I 
Avould mention. The first is in regard to 
McBurney's point. I have very little expe- 
rience mth it. Of course the appendix is a 
very movable organ, but Dr. ]Nracfarlane 



claims that if you put the end of your finger 
at the point he claims as diagnostic, that that 
pomt touches the base of the vermiform ap- 
pendix, and the base of it is always located 
in the same place unless the caecum is dis- 
placed. It may be so, but if so, the displace- 
ment is very common. I know Dr. Clark 
claimed great results for the opium treatment. 
He gave opium smiply according to effect 
only. If I am not mistaken he gave what 
are usually considered enormous doses, reduc- 
ing the respirations in some cases to 10 or 12 
per minute. Of coui-se these are enormous 
doses. I think no one to-day gives those 
enormous doses, and I know our results are 
no worse than Dr. Clark's were. I prefer the 
calomel treatment. If I had peritonitis I 
Avould not want to suffer very much pain, I 
A\'Ould want a dose of morphine, but as a rou- 
tine treatment, I think I would prefer the 
purgative treatment. When opium is given 
the bowels confine the fecal matter, which con- 
tains septic germs, and some of these cannot 
help getting into the general abdominal cav- 
ity. Septic peritonitis has often been pro- 
duced by an accumulation of fecal matter which 
could not be passed. Often cases of peri- 
tonitis are due to germs gettmg into the ab- 
dommal cavity through the bowels. Now 
purgation will carry that off'. 

Dr. Buchanan speaks of perforation of the 
vermiform appendix not always causing peri- 
tonitis, because it depended a good deal on the 
matter contained in the bowel, which then 
reaches the peritonal cavity. If it contained 
\Try malignant germs it would cause septic 
peritonitis. I believe that any perforation 
anywhere in the intestines or stomach, any 
perforation in the general peritoneal ca\TLty, 
will produuce septic peritonitis very suddenly 
and rapidly. Dr. Lange spoke of twelve 
cases of peritonitis which he treated, all of 
whicli recovered. That is certainly very for- 
tunate, and it is doubtful if his next twelve 
cases will be as fortunate. He may have a 
streak of bad luck in the treatment of these 
cases. I am certam a case of the kind 
of which I reported the post mortem will 
die, no matter under Avhat treatmentt, and 
die very suddenly, unless something sur- 
gical is done at once. The difficulty is 
in deciding when to operate and whether 
to operate, and the difficulty is to ascertain 
the exact condition of the tumor. If there 
were any special indications to determine the 
conditions inside, then we would know ex- 
actly what to do. The case may look favor- 
able, and at the same time a fatal accident is 
already present, and unless we operate early 
in sucii cases our results will be very bad. 



January 30, 1892. 



Society Reports. 



If you wait three days, in some cases, the 
patient may be dead, but to say you must 
operate on the third day, is perhaps too ar- 
bitrary ; on the other hand, the second day 
is very often too late. There are cases in 
which, if you want to giye the patient any 
chance for life, you must operate the fii-st day, 
as soon as you see the case, but the difficulty 
is, to tell that a case requires operation at 
once, and until we can make a more certain 
diagnosis, I think the surgeon is perfectly jus- 
tified on the third or fourth day, if the patient 
is in a very dangerous condition, to remoye 
the diseased appendix or abscess or pus. I 
think if he does ihat on the third or fourth 
day he yill haye a yery small mortality. If 
he waits until the last day, then his mortality 
will probably be 100 per cent. ; that is, if 
he waits, as one gentlemen here adyised, 
until perforation or coUapse sets in, there is 
no justification for operation and he need 
worry the family and jDatient no more. It is 
too late to operate. The gentleman also 
mentioned that pus should be demonstrated. 
If immediately under the abdominal ^vall, it 
is an easy thing to do, and in a case of that 
kind, puncture is hardly necessary. You can 
feel quite distinctly if pus is under the ab- 
dominal wall. If the pus is back of the 
caecum and }'ou run a needle into it and with- 
draw one, two or three drops of septic pus 
and smear it upon the the healthy peritoneum 
you can hardly help producing general septic 
2)eritonitis. I confess I lack courage to punch 
a needle back into the abdominal cayity, if I 
suspected pus. Dr. Lange also adyises explo- 
ration through the rectum to find pus. That 
has been recommended by quite a number of 
persons, and it is practiced to a great extent, 
but we are to remember that these abscesses 
are frequently so yery small that they may 
contain only a drachm or one or t^vo ounces 
of pus, and eyen if you push your whole hand 
into the rectum, if the abscess contains only 
a drachm or two of pus, you would not be 
able to recognize it by palpation, and yet a 
drachm or two of pus, when it gets into the 
abdominal cayity, yill be sufficient to cause 
death in twenty-four hours. Dr. Green speaks 
of the diagnosis of septic peritonitis by the 
general symptoms, pulse, expression, tempera- 
ture, etc. He says septic peritonitis is not 
yery difficult to diagnose and that eyery phy- 
sician ought to haye yery little difficulty in 
making a diagnosis of simple from septic perito- 
nitis. Probably in a majority of cases that is 
Cjuite true, but many cases of septic peritonitis 
present yery few symptoms and do not appear 
to be yery sick patients at all. They may 
haye no eleyation of temperature ; perhaps the 



only unfavorable sign you may notice in some 
of these cases is the very feeble pulse. I think 
this the most important diagnostic symp- 
tom in peritonitis, no matter whether the tem- 
perature is low or not. I do not think tem- 
perature has yery much to do ^nth the diag- 
nosis, but a yery rapid, feeble pulse and a lack 
of normal breathing, these are the most im- 
portant symptoms and the most dangerous 
symptoms. Pains and temperature are not 
yery important diagnostic points. Dr.'Lange 
spoke of a case of cholera morbus and septic 
peritonitis, in which it was impossible to say, 
when he saw the cases, Avhich of the two was 
the sicker man. The case in which I saw the 
post mortem examination began exactly like 
a case of cholera morbus. Violent vomiting, 
intense pains, and death in three days. He 
had a perforation of the appendix, perforation 
of the cieciim aiid pus all over the abdominal 
cayity. I suspect Dr. Lange's case to have 
been one of a sunilar kind. 

Report of cases followed : — 

De. Buchaxax : Five years ago I saw a 
case of croup in which it was necessary to in- 
troduce a tube. I opened the child's A^ind- 
pipe and put in a black rubber tube. The 
child was two years old and in three or four 
days, if I recollect correctly, I removed the 
tube, but the child had so much difficulty in 
breathing that I replaced it and left it in 
until the exjoiration of a week. I again re- 
moved the tube, and again this hard breath- 
ing came on. Some time after that I removed 
the tube and succeeded in keeping it out for 
two or three hours. At the end of that tune 
the hole had become so very small that it 
was mth the greatest difficulty I succeeded in 
getting it back before the child strangled. 
At intervals afterwards I removed that tube, 
and I at one time started to shorten it, and I 
thought if I would replace it each time with 
a shorter one I would, at length, have no tube 
at all, but when I got down to a certain de- 
gree of shortness I found the child could not 
breathe. I sometimes did not see the child 
for six months or a year. I was called to 
see the child about a month ago, and found 
that he had spasmodic croup, and also, to all 
appearances, there was no air coming through 
the tube. I endeavored to extract the tube 
and found the granulations had grown down 
in the opening, and when I pulled it up these 
points of tissue acted as a hook to hold the 
tube in place. I allowed the tube to remain, 
feeling comunced the child would get over 
this attack of croup. I saw him incidentally 
last Sunday and then withdrew the tube as 
far as possible and clipped this point off and 
extracted the tube. This point was about 



i86 



Selected FormulcB, 



Vol. Ixvi 



one-tliird or one-quarter of an incli long and 
as thick as a pen-holder. It was very tough 
tissue, covered with epithelium. The child 
since that time has been perfectly healthful. 
I mentioned this case about two or three 
years ago before this society, and I merely 
report the case now as closed. I would state 
that I saw this child this evening incidentally, 
and I believe the aperture is entirely closed, 
from the examination I made merely with 
my fingers, in endeavoring to open the parts 
up, and I believe the aperture has grown to- 
gether. It now has been two and one-half 
days since the tube was taken out. 

Dr Macfarlane: I saw Dr. McCann 
do this operation about fourteen years ago on 
a child named Murdoch. He was two years 
of age, and had diphtheritic croup. The 
child got well, and when an attempt was 
made to take out the tube he was immedi- 
ately seized with suflbcation, and we were 
obliged to replace it as quickly as possible. 
That was a silver tube. One day when we 
had removed the tube, which had been in 
some time, the outer shell was corroded and 
all eaten away, and there was nothing left 
but a very small portion of the inner shell. 
It was replaced by a rubber instrument, and 
it remained in the parts for a number of 
years. The rubber tube remained in, to my 
knowledge, until a year ago. On one occasion 
the boy had gone into the water and had 
waded in till this aperture was under ; he was 
then sixteen years of age. He immediately 
became suffocated, and had it not been for 
his brother, who came to his rescue, he would 
have succumbed. 



SELECTED FORMULA. 



COCAINE IN PERITONITIS. 



Dr. Julius G. Kiefer states, in the Kansas 
City Medical Index, that the distressing pain 
and vomiting of peritonitis may be promptly 
checked by a suppository containing one 
grain each : extract of opium, cocaine hydro- 
chlorate, and iodoform. It will be safe to use 
one suppository per rectum four hours apart, 
if the patient is closely watched for toxic 
effects, which may be noted by cold extrem- 
ities and enfeebled heart action. I was led to 
the employment of the above on the theory 
of the malignancy of the affection and re- 
versed peristaltic action of the bowel in peri- 
tonitis, and the well-known anaisthetic proper- 
ties of cocaine on' serous membranes. Ali- 
mentation should be temporarily suspended, 
and enema must be avoided until vomiting is 
checked. 

Any discussion will be thankfully received. 



OTALGIA. 

The following is recommended ( Ugesk- 
hift for Laeger^ Nos. 28 and 29, 1891) 
in otalgia : 

T>, Chi iral camphor grammes 5. 

-CM Glycerlni ' SO, . 

01. amygdalar. dulc " 10. 

Dip a wad of cotton into the mixture and place it in 

the ear. 

RINGWORM. 

T>. Ciipri oleate ; 5s3. 

-CM Adipis benzoati Si. 

M. FiHt uLgiieiit. tig Use locally. 

— Shoemaker, 

MALARIA. 

Sulphate of quinine grammes 12. 

Sulphate of iron " 6. 

Soft extract I f cinchona " 15. 

.For ten i>ills, "ne every tine ri hour.-<; exercise in the 
open air; suitable nourishment. Paint with tincture of iodine 
the hepatic or splenic region. 

FOR ASTHMA. 

A medical friend advises the following- 
formula, which I have found useful. I 
do not remember to have seen it in the 
text-books : 

T> Pot. iodidii Sij. 

fid. ext grindelia rtbusta 

Fid. ext. belladouna gr. xxv, 

Tr. gelsemium gr. xi. 

Aquas Sj. 

Elix. simpl ad g ij. 

M. Sig. One and a half teaspo nfuls every two or 
three hours until three doses are taken. Usually by the time 
the third dose is taken the tightness of breathing is gone. 

— C. S. Gray, M. D., Little Rock, in 
Jour, State Med. Society of Arkansas. 



HEMORRHOIDS. 
The following (// Raccoglitore Medico, 
No. 1 6, 1 891) is employed : 

T>, Cocain, mur gramme 1. 

JLV Morph. sulph " 0.25. 

Atrjpin. sulph " 0.20. 

Tannin polocrizat " 1. 

Vaselin grammes 36. 

Mix well and carefully. Apply locally once or twice 
daily, and especially after an evacuation. 



BICHROMATE OF, POTASH IN H^MATO- 
CHYLURIA. 

Dr. Manuel Delfin i^Cronica fnedico- 
quirurgica de la Habana, Tomo XVII, 
No. 17) has used the bichromate of 
potash with success in several cases of 
haemato-chyluria. He used the follow- 
ing formula : 

T) Potassii bichromat cgms. 5. 

Aquse destillat;B grammes 250. 

A teaspoonful on ri.siog and at meal times. 

The writer has no good theoretical 
reason for having used the remedy, but 
feels assured that in potassium bichro- 
mate we have a means of modifying 
that terrible disease, so difficult to suc- 
cessfully treat. 



January 30, 1892. 



Editorial, 



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LEADING ARTICLE. 



THE TREATMENT OF PHTHISICAL 
COUGH. 



The cough in phthisis is perhaps the most 
troublesome of all the symptoms we are called 
upon to treat. It cannot be said that all of 
the brilliant researches which have lately been 
made respecting the etiology and treatment of 
this disease have advanced our knowledge re- 
garding the management of this distressing 
symptom. We must still rely upon only clini- 
cal experience, and until the rational treat- 
ment recently proposed has shown itself of 
positive value, the symptomatic treatment will 
remain of chief practical value to practi- 
tioners of medicine. In nearly every case of 
consumption this symptom cough calls for 
treatment, and it is very often one of the 
gravest questions possible how it shall be prop- 
erly dealt with. Not only is it troublesome, 
annoying, and painful to the patient, l^ut it 
causes vomiting, loss of sleep, haemoptysis, 
pneumothorax and exhaustion when it is vio- 
lent and prolonged. For practical purposes 
the cough in phthisis may be divided into two 
kinds : (1) ineffectual and feeble ; (2) exces- 
sive. The very feeble, ineffectual cough is 
always a grave symptom when occurring in 
the later stages of consumption and associated 
with exhaustion and general debility. 

J. Mitchell Brace, M.A., M.D. L. K. C. 
P., Avho, from his large experience as a physi- 
cian to Charing Cross Hospital, and to the Hos- 
pital for Consumption, Brompton, is entitled 
to his high reputation as a teacher, has de- 
livered an excellent lecture upon this important 
subject (International Clinics, April, 1891, p. 
43), in which he discusses the treatment of 
cough, under headings referring to the time of 
its occurrence, as follows : 

(1) "Cough in the evening; (2) cough at 
bed-time ; (3) cough during the night ; (4) 
cough on waking, stimng, rising and dressing 
in the morning ; (5) cough after meals ; (6) 
excessive coughing any time, with or without 
abundant expectoration." 

This division seems a practical and rational 
manner of discussing the subject, and as a 



Editorial. 



Vol. Ixvi 



guide to the cause of the cough it commands 
itself as a routine method of thought. Cough 
in the evening may be due to the fatigue of 
the day and its consequent exhaustion, to 
over-heated rooms, tobacco smoke, bad air, 
or over-exertion on the part of the patient. 
The results are, as Bruce says, three-fold: 
"(1) Exhaustion; (2) rise of temperature; 
(3) cough." To prevent these and their bad 
effects upon the night's rest, the rational 
treatment of this symptom is to order such 
cases to retire early. Similarly, when cough 
at bedtime is a marked feature of any 
phthisical case it can very often be traced to 
sudden change of temperature, over-strain 
(going upstairs), etc., etc., and the most 
effective treatment will consist in the regula- 
tion of these bad conditions, and the strict 
avoidance of any of the causes which have 
been found to start the coughing. Should all 
the care possible in getting the patient up- 
stairs and to bed fail to prevent the attack, 
Bruce recommends the giving of a few drops 
of the spirits of chloroform combined with a 
little lemon juice and simple mucilage, and if 
this fails, a small amount of morphine. 

In cough occurring during the night, 
Avhich is usually due to an accumulation of 
secretion, reflex irritabihty of the nervous 
system from fever and general exhaustion, 
he directs the use of warm food and stimu- 
lants, and that morphine should be mthheld 
unless simple measures prove powerless to 
arrest the prolonged and useless attack ; while 
for morning cough the indications are to 
refresh the system, to assist expectoration and 
to avoid all narcotics. These should be met 
by an early breakfast, hot drinks, or nourish- 
ing broths, which, by stimulating the strength 
and increasing the secretions, assist expectora- 
tion. 

In dealing with ''cough after meal" 
Bruce confesses that for such paroxsyms the 
only therapeutic indication is " to arrest the 
unhappy symptoms, an indication far too 
general to be of much service in the selection 
of a remedy." Cough at this time is very com- 
monly attended by vomiting, and so nutrition 
rapidly fails. The main thing is to avoid 
large or habitual doses of narcotic sedatives. 



Avhich very soon have a disastrous effect on 
the digestive ftmctions, and sohasten the end. 

Finally, Bruce discusses the control of 
violent cough occurring at any time, and 
advises the use of the follomng local 
measures, viz. : Swallomng of pounded ice, 
menthol inhalations, warm alum spray, moi - 
phine insufflations with double the quantity 
of powdered starch, inhalation of a few drops 
of chloroform on lint. 

For "obstinate cough" Dr. Roland G. 
Curtin, of Philadelphia, who may justly be 
considered an American authority upon 
diseases of the chest, has brought to the 
notice of the profession the oil of sandalwood 
(Phila. Hosp. Reports, Vol. 1, 1890). Dr. 
Curtin thus summarizes his experience with 
this remedy in the wards of the Philadelphia 
Hos]3ital and in private practice. 

" In the first stage of phthisis the remedy 
acted in a very satisfactory manner, giving 
comfort and great relief to the patients when 
the cough was very troublesome. Sleep was 
prolonged and less disturbed and appetite 
was improved. In the second and third 
stages of phthisis, where the medicine ^vas 
well received by the stomach, it added greatly 
to the comfort of the patient, greatly reliev- 
ing the strain of coughing. 

" In the cough of catarrhal pneumonia, it 
not only acted as an immediate quietant of 
the cough, but also in a number of cases it 
seemed to, have a curative effect, the improve- 
ment being prompt and very decided. The 
proftise tenacious secretion was changed by 
Uquefying it, which relieved the distressing 
symptoms, and it was finally diminished in 
quantity." 

Dr. Curtin's claims regarding the value 
of sandalwood oil in the treatment of phthi- 
sical cough are based upon its local and 
general effects, as known to the profession all 
over the world in the treatment of urethritis, 
and the advantages which he points out from 
its use in preference to opiates are the im- 
mediate relief usually afforded, no impair- 
ment of appetite, unless it disagrees "with the 
stomach (as it sometimes does), no constipa- 
ting tendency, nor does the dose have to be 
increased after a while. 



January 30, 1892. 



Book Reviews, 



But the coiigli of phthisis is one which 
can never be treated by a set formula ; each 
case must be dealt mth according to the cir- 
cumstances present. The value of hygienic 
measures cannot be over estimated, and the 
use of simple and rational means to the ex- 
clusion, as much as possible, of opiates, 
should always be adopted. In the ftiture, it 
may be, we shall annihilate cough by directly 
attacking the cause of phthisis, but in the 
mean time we are dependent upon what bed- 
side experience has taught us. 

BOOK REVIEWS. 



MICROSCOPICAL DIAGNOSIS OF TUBER- 
CULOSIS. By PauIv Paouin, M. D., late 
Professoi of Microscopy, Bacteriology, etc., 
and Director of the Laboratory of Pathology, 
Medical Department, Missouri University, 
etc. Published by The Little Blue Book Co'., 
Battle Creek, Mich. 24mo., 48 pp. 

This httle hand book has evidently been 
prepared with a view of affording those inex- 
perienced in the study of the bacilli of tuber- 
culosis the proper data to enable them to do 
such work readily, especially to put the means 
in the hands of the general practitioner by 
which many severe cases of consumption can 
easily be diagnosed. 

The author refers very succinctly to the 
microscope and other instruments employed 
in the study of this kind of bacteria; the 
principle, object, and effect of staining; 
mounting ; collecting sputum, etc. ; staining 
fluids and their use ; and various other in- 
teresting matters. 

There are three handsome colored litho- 
graph plates of the bacilli, besides a number 
of wood-cuts. It will be found a very useful 
manual. 



AN INTRODUCTION TO HUMAN PHYSI- 
OLOGY. By Augustus Wai.i.er, M. D., 
Lecturer on Physiology at St. Mary's Hospi- 
tal Medical School, London ; late Kxternal 
Examiner at the Victoria University. Lon- 
don and New York : Longmans, Green & 
Co. 1 89 1. 8vo., 612 pp., 292 illustrations. 

This is, on the whole, the most satisfactory 
text-book that has been published since the 
first appearance of the novr classical work of 
Dr. Foster. Dr. Waller's presentation of the 
subject is particularly notable because of its 
bre^dty, clearness of expression, excellent 
style, originality, and absence of anatomical 
and histological details. AYhile the author has 
been brief, he has not neglected that which 
should be found in a book of this character ; 



nor can it be said on this account that the 
text is a mere summary of physiological data. 
The matter is not only presented wdth remark- 
able clearness, but wdth such originahty and 
excellence of style, that the whole work has a 
distmct air of freshness. 

The book bears evidence that the author is 
a careful and clear thinker, a thorough physi- 
ologist, and conscientious worker. It contains 
very few errors and omissions, it is well 
pruited, and excellently illustrated, and alto- 
gether most admirable, and mil undoubtedly 
meet with immediate and great success. 



CORRESPONDENCE. 



ANTISEPTIC FOR THE GRIPPE. 

To THE Editor of the Medical and 
Surgical Reporter: — The best antiseptic 
for influenza, or La Grippe, is sulphite of 
sodium, 5 grains, every two hours till all pain 
leaves the system. My prescription is : — 

T> Sodii Sulphit 5iv. 

JLM Aq a? fSvi. 

M. S. — A teaspooiiful in as mncb >• ater every two hours till 
all pain is relieved and the patient is well. 

Yours truly, 
J. A. MoxELL, M. D., 

New York City. 



GLYCERINE FOR BURNS. 

M. Grigoresen, of Bucharest, highly 
recommends pure glycerine as a remedy for 
burns. On first application a slight burning 
feeling is experienced, which soon gives away 
to a local anaesthesia, somewhat resembling 
that produced by carbolic acid. In severe 
cases two or three applications should be 
made, so that the parts are kept wet con- 
stantly with the glycerine. Under this treat- 
ment the inflammation is subdued almost 
completely, and only a slight cicatrix is 
usually left. 



TO HASTEN DESQUAMATION IN SCAR- 
LATINA. 

Dr. Jamieson (JVorsk Mag. for Lcegeviden- 
skaben, 'No. 11, 1891) has employed 30 per 
cent of carboHc acid in oil mth good results, 
but resorcine has served him better. This 
latter is combined with salicylic acid and 
employed in the form of a superfatted soap. 
The patients are anointed with this when 
desquamation begins ; after this the skin is 
rubbed with some indiflferent fatty substance. 
The nurse should wear rubber gloves to pro- 
tect her hands. With these means the 
writer has shortened the period of desquama- 
tion from 55.5 to 40.26 days. 



Periscope, 



Vol. Ixvi 



PERISCOPE. 

MEDICINE. 

THE REIvATION OF FUNCTIONAL DIS- 
ORDERS OF THE HEART TO DIS- 
EASES OF THE ABDOMINAL 
VISCERA. 

Dr. Taylor, in his most interesting 
paper, in The Practitioner, draws attention 
to the association of cardiac derangements 
with abdominal visceral diseases, and 
records fifteen cases met with during the 
last four years. 

The cases are divided into two clinical 
groups : 

I. Violent and frequent action of the 
heart (palpitation, tachycardia, or heart- 
hurry). 

Three cases are recorded : 

Case I. — lyady, past middle age. Par- 
oxysmal attacks of violent palpitation, 
260 and more beats per minute. Attacks 
of sudden onset, and would cease sud- 
denly. They were excited by sudden 
noise, as slamming of a door, or any 
mental emotion, and a similar event 
would arrest the heart's gallop and re- 
duce its action to normal frequency. A 
movable right kidney subsequently de- 
tected. Death occurred. No autopsy. 

Case 2. — lyady. Paroxy